Health Record for Acute

Care

Health Record Documentation

In the Acute Care Setting
Cassandra Booe
The Health Record, Sec 001

Acute care facilities provide many different diagnostic and therapeutic

services. Complete and accurate documentation in this type of setting

Health Record for Acute

Care

improves healthcare quality, efficiency, and patient safety. Whether paperbased or electronic, health records are an absolute necessity and it is the
responsibility of the acute care facility to develop and maintain uniformity
within those records.
In order to maintain uniformity within a paper based health record
system, all employees accessing those records must follow a specific chart
order put in place by the acute care facility. This can be difficult to do in any
situation, however it can be a major issue for bigger facilities that have more
workers accessing those records. Another limitation to this type of system is
that a record may only be accessed by one person at a time. This means that
the record may often be unavailable to someone else who needs to use it.
Records stored this way may be difficult to update as well. If one department
is needing to add newer documentation to the record, but it is unavailable or
has not been returned to the correct department, then it causes delays in
having updated documentation on that particular patient. One last limitation
to this type of system is that paper documentation is more susceptible to
damage. Due to financial limitations in making a copy of every single piece
of documentation, health records can be easily misfiled, damaged, or lost. A
solution to these limitations would be to implement an electronic health
record (EHR) system.
Many of the problems and limitations of a paper-based health record
system do not exist when using electronic health records. Many EHRs are
accessible through computer networks meaning that several different

Health Record for Acute

Care

employees in different departments can access and update the records at

the same time. Because EHRs can be stored in a variety of electronic media,
they can be backed up quickly, stored at an offsite location in case of a
natural disaster, and are much safer from damage and loss than health
records stored in a traditional paper-based system. This all sounds fantastic
and it is because it is much more efficient for acute care providers, however
there can be some major issues. One of the biggest issues with an EHR
system is the sheer cost of getting it started. It is expensive to purchase the
program and can be even more expensive to implement. Training all of the
employees to completely understand how to use the system takes a lot of
money and time. Even though it can save money in the long run, cut down
on liability risks, and increase patient safety, the initial costs of implementing
an electronic system can and sometimes does keep acute care facilities from
making the transition. However, because completeness is important in order
to maintain continuity of care, it would in the companys best interest to
invest in an EHR system. Acute care is normally provided to patients who
have severe and usually brief conditions so it is important that the record by
updated as frequently as possible.
The primary function of the health record is to show services that were
provided to the patient by the providing facility. It is the legal business record
for the provider, therefore the contents in the record should pertain only to
the services rendered to the patient by that facility. The exception to this is
when records made by other providers are directly used in the care of the

Health Record for Acute

Care

patient at the new facility. In many acute care facilities, it is the Health
Information Management (HIM) professionals who are responsible for
maintaining and evaluating every patient health record after the patient has
been discharged. HIMs may also perform reviews of the health record while
the patient is still currently receiving treatment. This helps to ensure
complete and accurate documentation of that patients health record.
Qualitative improvement and accreditation organizations use the health
record to ensure that quality care is being provided to the patient. In addition
to this, complete and accurate documentation helps in the coding and billing
process so that the company is reimbursed appropriately for the services
rendered.
There are several components of the health record that must be
present, maintained, and updated as required and needed. First, the health
record must contain admission and consent forms. This section includes the
demographics of the patient, such as name, date of birth, address, phone
number, insurance information, etc. It also includes resuscitation
instructions, a Living Will, Power of Attorney, emergency contact information,
and if the patient is an organ donor. A second component is the history and
physical. This is completed by the physician or his designee within a required
time frame and contains information about past illnesses, the present
condition that brought the patient to the hospital, any known allergies, etc.
Another part of the health record is the physicians orders. There must be a
physicians order before treatment can begin. Even if an order is given

Health Record for Acute

Care

verbally over the phone, it must be written, reviewed, and signed so that it
can be placed in the patients health record. All orders must be signed and
dated by the physician. Physician and nurse progress notes make up another
component of the health record. There must be ongoing documentation
showing the treatment planned, the patients response to it, daily
observations, vital signs, and any medications given to the patient. Another
component you will find in an acute care health record is ancillary services
and consultation records. This section consists of radiologic findings, lab
reports, surgical consultations and reports, pathology reports, and specialty
care. Discharge summaries are also part of every patients health record. The
summary includes the patients condition upon discharge, the physicians
instructions for after care, and progress made during treatment. If the
patient is being transferred to a different health care facility, then the
discharge summary will indicate that as well. These are just a few of the
basic components you will find in an acute care health record. Depending on
regulations, accreditation standards, state guidelines, and company policy,
there may be additional documentation kept and maintained in the health
record.
In order for an acute care facility to be compliant with the Centers for
Medicare and Medicaid Services regulations regarding quality and
reimbursement, the facility must perform clinical documentation
improvement (CDI) functions. Acute care hospitals have become very
dependent on physician documentation in order to comply with CMS. There

Health Record for Acute

Care

are several different tasks that can be done to make sure the facility is
staying compliant with CDI functions. HIM professionals can help in this
process by identifying any missing, conflicting, or nonspecific physician
documentation. They can provide support to coders to make sure everything
is being coded correctly, make sure the health record is being maintained
and up to date during the patients stay, help to improve communication
between the physician and other clinicians, and improve documentation to
reflect quality and outcome scores.
Studies have shown that the most common documentation to be
reviewed are diagnostic results and physician documentation. With that
being said, it is very important that acute care facilities continue to provide
education to all clinicians on proper documentation in order to maintain an
effective and accurate health record. Health records are inspected to ensure
that patients are being seen as often as required by regulations. In acute
care, a nurse should make an entry in the health record a minimum of once a
shift and an entry by an assistant in nursing should not be the only entry in
the record for that shift. In addition to that, medical practitioners should
make an entry in the health record at the time of the event or as soon as
possible afterwards. And finally, other health care professionals should make
entries to reflect their level of participation as well.
Every acute care facility must develop policies to ensure the uniformity
and effectiveness of health record content regardless if they are maintained
in a paper or an electronic format. As was mentioned earlier, complete and

Health Record for Acute

Care

accurate documentation in this type of setting improves healthcare quality,

efficiency, and patient safety. Complete and accurate documentation also
greatly benefits the provider because it is absolutely necessary in order to
receive correct reimbursement for services rendered during a patients stay.

Resources:

Penoyer, D. Cortelyou-Ward, K. Noblin, A. Bullard, T. Talbert, S. Wilson, J.

(2014). Journal of
healthcare management. Use of electronic health record
documentation by health care workers in an acute care hospital
system. (59.2, 130).

Health Record for Acute

Care

http://go.galegroup.com.proxy.libraries.uc.edu/ps/i.do?
p=EAIM&u=ucinc_main&id=GALE|
A384340816&v=2.1&it=r&sid=summon&userGroup=ucinc_main&auth
Count=1

AHIMA. (2004). Documentation for acute care. (14-46 ).

http://library.ahima.org/xpedio/groups/public/documents/catalog/bok1_01586
2.pdf

AHIMA. (2011). HIM functions in healthcare quality and patient safety. Journal
of ahima. (82, 8).
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_0
49163.hcsp?dDocName=bok1_049163

NCBI. (2014). Use of electronic health record documentation by healthcare

workers in acute
care hospital system. http://www.ncbi.nlm.nih.gov/pubmed/24783371

NSW Government. (2012). Health care records documentation and

management. (11).
http://www0.health.nsw.gov.au/policies/pd/2012/pdf/PD2012_069.pdf