E-Discovery: A Deposition for your Electronic Health Record

E-Discovery: A Deposition for your Electronic Health Record Sponsored by 1915 N. Fine Ave #104 Fresno CA 93720-1565 Phone: (559) 251-5038 Fax: (559) 251-5836 www.californiahia.org Supplemental Handouts Wednesday, June 10, 2015 Track Two 9:20am-10:20am 2015 State Convention and Exhibit Speaker Diane Premeau, MBA, MCIS, RHIA, CHP, CHC Copyright California Health Information Association, AHIMA Affiliate

REFERENCES: Title 22 California Code of Regulations, Sections 70749, 70527, 70751, and 71549 Amatayakul, Margret et al. "Definition of the Health Record for Legal Purposes (AHIMA Practice Brief)." Journal of AHIMA 72, no. 9 (2001): 88A-H. AHIMA e-him Work Group on the Legal Health Record. "Update: Guidelines for Defining the Legal Health Record for Disclosure Purposes." Journal of AHIMA 76, no.8 (September 2005): 64A-G. Medical Staff Bylaws, Rules and Regulations? Health Insurance Portability and Accountability Act (HIPAA) Privacy & Security Rule, 45 CFR 160-164 California Medical Information Act, Civil Code Section 56 et seq. Medicare Conditions of Participation, 42 CFR Section 482.24 Business Records Exception, Federal Evidence 803(6) California Healthcare Association Manual Authentication sections ASTM, Standards Guide for Amendments to Health Information. Designation E 2017-99. LHM Record Retention Policy and Procedure The Joint Commission CAMH (Accreditation Manual for Hospitals). AHIMA, Update: Maintaining a Legally Sound Health Record Paper and Electronic, Practice Brief, 2003. AHIMA, Guidelines for EHR documentation to Prevent Fraud, Practice Brief AHIMA Convention and IFHRO Proceedings, (Helbig, S, 2004) Copying and Pasting in the EHR-S: An HIM Perspective, Definition Content, Business record PRINICPLES The Legal Medical Record (LMR) is the documentation of services provided to an individual during any aspect of healthcare delivery and is patient-centric. The legal health record contains individually identifiable data, stored on any medium, collected and directly used in documenting healthcare or health status. The legal health record is the business record and is the record that will be disclosed upon request. How record created & by whom The Legal Medical Record at may be a hybrid record utilizing both paper-based and electronic documents, which are captured manually and via electronic processes. Only individuals authorized to do so by Hospital and/or Medical Staff Policies and Procedures make entries into the Legal Medical Record. Objectives of standards; reiteration of CMS standard PURPOSE The Legal Medical Record definition and standards set forth in this Policy provide a framework for the integrity of paper and electronic clinical documentation systems that compile and maintain Legal Medical Records to meet patient care and regulatory requirements. The Legal Medical Record contains sufficient information to identify the patient, support the diagnosis, justify the treatment and services, document the course and results of care, and promote the continuity of care among health providers. 1 of 14 Copyright California Health Information Association, AHIMA affiliate 1

DEFINITIONS 1. Amendment additional documentation added after original documentation has already been authenticated. 2. Ancillary File: A folder containing COPIES ONLY of information from the Medical Record used primarily by clinicians in their office or clinic setting. These COPIES of the relevant documents from the original Medical Record are NOT part of the Legal Medical Record. 3. Alteration amendments which intentionally change the content or character of health information in the EHR for less than honorable purposes; tampering. 4. Authentication - the process that ensures that users are who they say they are. The aim is to prevent unauthorized people from accessing data or using another person's identity to sign documents. 5. Authentication: The process that ensures that users of PHI are who they say they are. The aim is to prevent unauthorized people from accessing data or using another person's identity to sign documents. 6. Author a person or system that originates or creates information that becomes part of the record. 7. Business Record - a record made or received in conjunction with a business purpose and preserved as evidence or because the information has value. Because this information is created, received, and maintained as evidence and information by an organization or person, in pursuance of legal obligation or in the transaction of business, it must consistently 8. Medical Record: The collection of information concerning a patient and his/her health care that is created and maintained in the regular course of business in accordance with policies, made by a person who has knowledge of the acts, events, opinions or diagnoses relating to the patient, and made at or around the time indicated in the documentation. The Medical Record may include records maintained in an electronic medical record system, e.g., an electronic system framework that integrates data from multiple sources, captures data at the point of care, and supports caregiver decision making. The information may be from any source and in any format, including, but not limited to print medium, audio/visual recording, and/or electronic display. Defining content and data elements Inclusion of external records The Legal Medical Record may include source data in the absence of documentation or interpretations. When physically required to be stored in a separate location, this information will be given the same level of confidentiality and control as the Legal Medical Record. Examples of source data include fetal monitor strips and/or treadmill tracings. The Medical Record may also be known as the Legal Medical Record (LRM) in that it serves as the documentation of the healthcare services provided to a patient by a hospital, clinic, physician or provider and can be certified by the Record Custodian(s) as such. The Legal Medical Record may include records from other health care providers as the result of tests and exams when necessary for the evaluation of the patient and subsequent treatment. 2 of 14 Copyright California Health Information Association, AHIMA affiliate 2

The Legal Medical Record is a subset of the Designated Record Set (DRS) and is the record that will be released for legal proceedings or in response to a request to release patient medical records. The Legal Medical Record can be certified as such in a court of law. 9. Designated Record Set ( DRS ): A group of records that includes Protected Health Information (PHI) that is maintained, collected, used or disseminated by, or for, a covered entity (e.g. LHM) for each individual that receives care from a covered individual or institution. The DRS includes: The medical records and billing records about individuals maintained by or for a covered health care provider (can be in a business associate s records); The enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; and The information used, in whole or in part, to make health care decisions about individuals. 10. Protected Health Information ( PHI ): PHI is individually identifiable health information that is transmitted or maintained in any medium (including oral statements), regarding a patient s medical history, mental or physical condition or treatment that includes or contains any element of personal identifying information sufficient to allow identification of the individual such as the patient s name, address, e-mail address, telephone number, social security number, or other information that, alone or in combination with other publicly available information, reveals the individual s identity. 11. Signature: A signature identifies the author or the responsible party who takes ownership of and attests to the information contained in a record entry or document. 12. Source Data: The origin of information found in electronic media. The acceptance of these transaction records into any new system could be very important for any verification of such imported data. POLICY I. Maintenance of the Medical Record A. A Medical Record shall be maintained for every individual who is evaluated or treated as an inpatient, outpatient, or emergency patient of a hospital, clinic, or physician s office. B. Currently, the Medical Record is considered a hybrid record, consisting of both electronic and paper documentation. Documentation that comprises the Medical Record may physically exist in separate and multiple locations in both paper-based and electronic formats. (See Appendix A). What is part of your record emails??? C. The Medical Record contents can be maintained in either paper (hardcopy) or electronic formats, including digital images, and can include patient identifiable source information, such as photographs, films, digital images, electronic messages (e.g. emails) and fetal monitor strips. D. The electronic components of the Medical Record consist of patient information from multiple electronic health record source systems. 3 of 14 Copyright California Health Information Association, AHIMA affiliate 3

E. Original medical record documentation must be sent to the designated medical record department or area. Whenever possible, the paper chart shall contain original reports. F. The paper Medical Record must be returned to the Medical Records Department as soon as it is no longer required for patient care or as outlined in policy and procedure. II. Confidentiality A. The Medical Record is confidential and is protected from unauthorized disclosure by law. The circumstances under which use and disclose of confidential PHI is set forth in the Notice of Privacy Practices. B. Personnel who access the electronic Medical Record are required to have a unique user ID and password, and access to information is limited according to the minimum necessary rule and managed by role, as approved by designated management personnel. III. Content A. Medical record content shall meet all State and Federal legal, regulatory and accreditation requirements including but not limited to Title 22 California Code of Regulations, sections 70749, 70527 and 71549, and the Medicare Conditions of Participation 42 CFR Section 482.24. Appendix A contains a listing of medical record documentation content, and current electronic or paper format status. B. Additionally, all hospital records and hospital-based clinic records must comply with the applicable hospital s Medical Staff Rules and Regulations requirements for content and timely completion. Guidelines for identification sets standards for electronic systems (2 identifiers each page) C. All documentation and entries in the Medical Record, both paper and electronic, must be identified with a minimum of two identifiers, preferably the patient s full name and a unique number. Each page of a double-sided or multi-page form must be marked with both the patient s full name and the unique identifier, since single pages may be photocopied, faxed or imaged and separated from the whole. D. All Medical Record entries should be made as soon as possible after the care is provided, after an event occurs, or after an observation is made. An entry for the actual patient treatment or procedure will never be made in the Medical Record in advance of the service provided to the patient. E. Only forms/reports approved can be used to document or capture data in the Legal Medical Record. Organization (may want to define a specific dept (HIM, IS??) will track what systems and formats were available when healthcare decisions were made. Address drafts & authentication - versioning F. Preliminary reports/documents are available for patient care until they are authenticated. Once a document/report has been authenticated by the author (Final version) only that version is electronically displayed or filed in the paper chart. 4 of 14 Copyright California Health Information Association, AHIMA affiliate 4

G. Only approved abbreviations will be used in the legal medical record. The do not use abbreviations, acronyms, symbols, and dose designations will apply to all orders and all medication-related documentation that is handwritten or entered as free text into a computer. Standard for authentication Do you have an electronic signature policy? IV. Who May Document Entries in the Medical Record Only authorized employees or approved clinical and social services providers may document in the Medical Record based on scope of practice, clinical affiliation agreements, and/or designation by LHM Policies & Procedures and /or Medical Staff Bylaws or hospital policy. V. Completion, Timeliness and Authentication of Medical Records A. All inpatient Medical Records must be completed within 14 days from the date of discharge. Additional requirements may also be included in the applicable LHM Hospital Medical Staff By-Laws and/or Rules and Regulations. B. All ambulatory Medical Records will be completed immediately following the encounter. C. All operative and procedure reports will be completed immediately after surgery. D. All Medical Record entries are to be dated, the time entered, and signed. E. Certain electronic methods of authenticating the Medical Record, including methods such as passwords, access codes, or key cards may be allowed provided certain requirements are met. The methodology for authenticating the document electronically must comply with electronic signature policy. The entries may be authenticated by a computer key, in lieu of a medical staff member s signature, only when that medical staff member has placed a signed statement with the Medical Center to the effect that the member is the only person who: 1) has possession of the key (or sequence of keys); and 2) will use the key (or sequence of keys). F. Fax signatures are acceptable. VI. Ownership, Responsibility, and Security of Medical Records Release of LHR A. All Medical Records of patients, regardless of whether they are created at, or received by, and all patient lists and billing information are the property of (Organization). The information contained within the Medical Record must be accessible to the patient and thus made available to the patient and/or legal representative upon appropriate request and authorization by the patient or legal representative. B. The Custodian of Records is designated as the person who assures that there is a complete and accurate Medical Record for every patient. The medical staff and other health care professionals are responsible for the documentation in the Medical Record within required and appropriate time frames to support patient care. 5 of 14 Copyright California Health Information Association, AHIMA affiliate 5

C. Original records may not be removed from facilities and/or offices except by court order or as otherwise required by law. If an employed physician or provider separates from or is terminated for any reason, they may not remove any original Medical Records, patient lists, and/or billing information from the facility and/or offices. For continuity of care purposes, and in accordance with applicable laws and regulations, patients may request that a copy of their records be forwarded to another provider upon written request. D. Medical records shall be maintained in a safe and secure area. Safeguards to prevent loss, destruction and tampering will be maintained as appropriate. Records will be released from Health Information Management Services only in accordance with the provisions of this policy and other Privacy Policies and Procedures. Management of Special Records E. Special care must be exercised with Medical Records protected by the State and federal laws covering mental health records, alcohol and substance abuse records, reporting forms for suspected elder/dependent adult abuse, child abuse reporting, and HIV-antibody testing and AIDS research. VII. Retention and Destruction of Medical Records All Medical Records shall be retained for as long as required by State and federal law and regulations and by policies and procedures. Paper and Electronic record retention How to manage records that can not be located A. Organization has written backup procedures to ensure retention and protection against data loss. B. Health records are stored to prevent loss, destruction, or unauthorized use, disclosure or release. C. Paper records may be stored in open-space shelving for active files and off site box storage for archived records. D. Electronic health record systems provide basic database storage standards, including appropriate security measures. E. Paper documents are destroyed based upon specific department policies after scanning into the EHR. F. Electronic health records will be archived based on applicable facility specific policy and in accordance with state and regulatory requirements. G. In the event that an original paper Medical Record cannot be located, a recreated replacement Medical Record will be created as required. VIII. Maintenance and Legibility of Medical Records A. All Medical Records, regardless of form or format, must be maintained in their entirety, and no document or entry may be deleted from the record, except in accordance with the destruction policy. B. Handwritten entries should be made with permanent black or blue ink, with medium point pens. This is to ensure the quality of electronic scanning, photocopying and faxing of the document. All entries in the Medical Record must be legible to individuals other than the author. 6 of 14 Copyright California Health Information Association, AHIMA affiliate 6

How to handle Downtime Documents C. Documentation created during downtime processes will be sent to the Medical Records Department for inclusion in the Legal Medical Record. Direct online data entry systems will establish downtime procedures to assure the integrity of patient information and continuity of patient care. IX. Corrections and Amendments to Medical Records Any questions related to correcting a final copy should be referred to the health information management department and/or compliance. When a correction is required in a Medical Record entry, the original entry must not be Obliterated, and the inaccurate information should still be accessible and legible. Corrections to outside provider information Correcting Scanned Documents Corrections to point of care systems If records requiring correction are from an outside provider, the patient should be instructed to contact the originator for an amendment. The correction must indicate the reason for the correction, and the correction entry must be dated and signed by the person making the revision. Examples of reasons for corrected entries may include wrong patient, etc. The contents of Medical Records must not otherwise be edited, altered, or removed. Patients may request an amendment of and/or an addendum to their Medical Record. A. Correction of documents created in a paper format: 1. Do not place labels over the entries for correction of information. 2. If information in a paper record must be corrected or revised, draw a line through the incorrect entry and annotate the record with the date and the reason for the revision noted, and signature of the person making the revision. 3. If the document was originally created in a paper format, and then scanned electronically, the electronic version must be corrected by printing the documentation, correcting as above in (2), and rescanning the document. B. Documents that are created electronically must be corrected by one of the following mechanisms: 1. Adding an addendum to the electronic document to indicate the corrected information, the identity of the individual who created the addendum, the date created, and the electronic signature of the individual making the addendum. 2. Preliminary versions of transcribed documents may be edited by the author prior to signing. A transcription analyst may also make changes when a nonclinical error is discovered prior to signing (i.e., wrong work type, wrong date, wrong attending assigned). 3. Once a transcribed document is final, it can only be corrected in the form of an addendum affixed to the final copy as indicated above. Examples of documentation errors that are corrected by addendum include: wrong date, wrong location, duplicate documents, or incomplete documents. The amended version must be reviewed and signed by the provider. C. When a pertinent entry in the Medical Record was missed or not written in a timely manner, the author must meet the following requirements: 1. Identify the new entry as a late entry 7 of 14 Copyright California Health Information Association, AHIMA affiliate 7

2. Enter the current date and time do not attempt to give the appearance that the entry was made on a previous date or an earlier time. The entry must be signed. 3. Identify or refer to the date and circumstances under which the late entry or addendum is written. 4. When making a late entry, document it as soon as possible. There is no time limit for writing a late entry; however, the longer the time lapse, the less reliable the entry. D. An addendum is another type of late entry that is used to provide additional information in conjunction with a previous entry. 1. Document the date and time on which the addendum was made. 2. Write addendum and state the reason for creating the addendum, referring back to the original entry. 3. When writing an addendum, complete it as soon as possible after the original note. E. Errors in Scanning Documents (if applicable) If a document is scanned with the wrong encounter date or to the wrong patient, the following process will be followed: 1. Reprint the scanned document. 2. Rescan the document to the correct date or patient, and if necessary, store the incorrectly scanned document in a non-viewable folder in the permanent document repository. F. Electronic Documentation Direct Online Data Entry Note: The following are guidelines for making corrections to direct entry of clinical documentation, and mechanisms may vary from one system to another. 1. In general, correcting an error in an electronic/ computerized Medical Record should follow the same basic principles as corrections to the paper record. 2. The system must have the ability to track corrections or changes to any documentation once it has been entered or authenticated. 3. When correcting or making a change to a signed entry, the original entry must be viewable, the current date and time must be entered, and the person making the change must be identified. Considerations Does your system ALLOW copy & Paste Does your organization acknowledge copy and paste G. Copy and Paste Guidelines The copy and paste functionality available for electronic Medical Records eliminates duplication of effort and saves time, but it must be used carefully to ensure accurate documentation and must be kept to a minimum. 1. Copying from another clinician s entry: If a clinician copies all or part of an entry made by another clinician, the clinician making the entry is responsible for assuring the accuracy of the copied information. 2. Copying test results/data: If a clinician copies and pastes test results into an encounter note, the clinical-provider is responsible for ensuring the copied data is relevant and accurate. 8 of 14 Copyright California Health Information Association, AHIMA affiliate 8

Identify the TYPES of E-signatures in existing systems. Can your system /vendor meet your standards? 3. Copying for re-use of data: A clinician may copy and paste entries made in a patient s record during a previous encounter into a current record as long as care is taken to ensure that the information actually applies to the current visit, that applicable changes are made to variable data, and that any new information is recorded. X. Authentication of Entries in Medical Records A. Electronic signatures must meet standards for: 1. Data integrity to protect data from accidental or unauthorized change (for example locking of the entry so that once signed no further untracked changes can be made to the entry); 2. Authentication to validate the correctness of the information and confirm the identity of the signer (for example requiring signer to authenticate with password or other mechanism); 3. Non-repudiation to prevent the signer from questioning that they signed the document (for example, public/private key architecture). At a minimum, the electronic signature must include the full name and either the credentials of the author or a unique identifier, and the date and time signed. B. Electronic signatures must be affixed only by that individual whose name is being affixed to the document. C. Countersignatures or dual signatures must meet the same requirements, and are used as required by State law and Medical Staff Rules and Regulations. D. Initials may be used to authenticate entries on flow sheets or medication records, and the document must include a key to identify the individuals whose initials appear on the document. F. Documents with multiple sections or that are completed by multiple individuals should include a signature area on the document for all applicable staff to sign and date. Staff who have completed sections of a form should either indicate the sections they completed at the signature line or initial the sections they completed. G. No individual shall share electronic signature keys/password with any other individual. XI. Designation of Secondary Patient Information The following three categories of data contain secondary patient information and must be afforded the same level of confidentiality as the Legal Medical Record, but they are NOT considered part of the Legal Medical Record. A. Patient-identifiable source data are data from which interpretations, summaries, notes, etc. are derived. They often are maintained at the department level in a separate location or database, and are retrievable only upon request. Examples include, but are not limited to 1. Photographs for identification purposes 2. Audio recordings of dictation notes or patient phone calls. 3. Video recordings of an office visit, if taken for other than patient care purposes 9 of 14 Copyright California Health Information Association, AHIMA affiliate 9

4. Video recordings/pictures of a procedure, if taken for other than patient care purposes 5. Video recordings of a telemedicine consultation 6. Communication tools (i.e., Kardex, patient lists, work lists, administrative inbaskets messaging, sign out reports, FYI, drafts of notes, or summary reports prepared by clinicians, etc.) 7. Protocols/clinical pathways, best practice alerts, and other knowledge sources. 8. A patient s personal health record provided by the patient to his or her care provider. 9. Medication reconciliation from an outside source (pharmacy, other providers) 10. Alerts, reminders, pop-ups and similar tools used as aids in the clinical decision making process. The tools themselves are not considered part of the Legal Medical Record. However, the associated documentation of subsequent actions taken by the provider, including the condition acted upon and the associated notes detailing the examination, are considered as component of the Legal Medical Record. Similarly, any annotations, notes and results created by the provider as a result of the alert, reminder or pop-up are also considered part of the Legal Medical Record. Some source data are not maintained once the data has been converted to text. Certain communication tools are part of workflow and are not maintained after patient's discharge. B. Administrative data are patient identifiable data used for administrative, regulatory, and healthcare operations and for financial purposes. While administrative data is provided the same level of confidentiality and control as the Legal Medical Record or designated record set they are NOT considered part of the Legal Medical Record. Examples include, but are not limited to: 1. Authorization forms for release of information 2. Correspondence concerning requests for records. 3. Birth and death certificates. 4. Event history/audit trails. 5. Patient-identifiable abstracts in coding system. 6. Patient identifiable data reviewed for quality assurance or utilization management. 7. Administrative reports. C. Derived data consist of de-identified information aggregated or summarized from patient records for statistical reporting, licensing and accreditation. While derived data are provided the same level of confidentiality and control as the Legal Medical Record, they are NOT considered part of the Legal Medical Record. Examples include, but are not limited to: 1. Accreditation reports 2. Best practice guidelines created from aggregate patient data. 3. External required reporting, public health records and statistical reports. D. Draft Documents / Work in Progress. Electronic processes and workflow management require methods to manage work in progress. These work-in-progress 10 of 14 Copyright California Health Information Association, AHIMA affiliate 10

documents often are available in the system as draft/interrupted documents, viewable to a limited number of users. Draft/Interrupted documents are not considered a part of the official Medical Record until they are finalized and signed by an authorized signer. XI. AUDIT TRAILS A. An audit trail is part of the metadata created around a document. It is composed of all transactions and activities, including access, associated with the health record. B. Elements of an audit trail may include date, time, nature of transaction or activity, and the individual or automated system linked to the transaction or activity. C. For the paper medical record an audit trail would be located in an electronic chart tracking system. 11 of 14 Copyright California Health Information Association, AHIMA affiliate 11

APPENDIX A - SAMPLE Each LHM to complete for specific documents Legal Medical Record Reference 1. ADMITTING INFO Inpatient Admission Registration sheet Conditions of Admission Code Status Orders Legal Status documents: Organ Donation Form 2. ADVANCE DIRECTIVES Advance Directive Alert Form Advance Directives Acknowledgement Transfusion Information Form Interfacility transfer sheet Health Facility Minor Release Report Discharge Summary Physician/Treatment Coordinator Discharge Summary Autopsy 3. PREADMIT SECTION Emergency Department Registration Sheet Pre-hospital care report (Medical Transportation) Triage Documentation/Nursing/Physician Chart (Computerized) Emergency Physician order sheet After-Care Instructions to the Patient Department of Emergency Medicine Agreement Nursing Assessment - Emergency Department 4. H&P/PROGRESS NOTES SPECIAL FORMS for NEWBORNS/ NICU Newborn Maturity Rating and Classification Newborn Nursery Growth Chart Premature Weight Chart Newborn Physical Exam Delivery Room Response Sheet Intrapartum Problem List Labor & Delivery H&P Obstetrical Record SPECIAL FORMS for OBSTETRICS OB Record Delivery Summary OB Physician's Risk Assessment Tools Admission/Discharge Postpartum/Discharge Prenatal History -1 (NCR copy from clinic) Prenatal Screening -2 (NCR copy from clinic) Intrapartum Problem List Labor and Delivery H&P Postpartum Course (after last PN) SPECIAL FORMS for PSYCHIATRY Nutritional Screening 12 of 14 VIEWING LOCATION(S) Source System Copyright California Health Information Association, AHIMA affiliate 12 Designated Record Set

APPENDIX A - SAMPLE Each LHM to complete for specific documents History & Physical (709F): Typed Report, Acute Psychiatric Services History and Physical (6833) Progress Notes Post Operative Progress Note Final Progress Note/Discharge Summary Discharge Prescription Order Form page 2 of Final Progress note. Discharge Summary Consultations 5. LAB 6. RADIOLOGY 7. OTHER DIAGNOSTICS Adult Echocardiography Requisition (9862) Echocardiograms, EEGs, EKGs GI forms Holter Monitor Spirometry Treadmill Stress Test EMG Newborn Hearing Screening Infant Reporting Form Cardiac Cath 8. PROCEDURE/OPERATIVE SECTION Procedure/Operative reports Surgical Pathology Report Operating Room/L&D charge Pre-op Questionnaire/Instructions Verification of Surgical Procedure and Surgical Site Surgical Consent/Consent for Treatment Sterilization Authorization Short Stay Flowsheet Anesthesiology Record PACU Order Sheet PACU Record Record of Implanted Devices Post Op Instructions Cath reports Bronchoscopy reports 9. TREATMENT SECTION: Dialysis documents RESPIRATORY CARE PHYSICAL THERAPY OCCUPATIONAL THERAPY SPEECH PATHOLOGY RECREATIONAL THERAPY 10. RESTRAINTS AND SECLUSION Seclusion/Restraint Order Form Seclusion/Mechanical Restraint Observation Form 13 of 14 Copyright California Health Information Association, AHIMA affiliate 13

APPENDIX A - SAMPLE Each LHM to complete for specific documents Seclusion/Mechanical Restraint Documentation Form Restraint and Seclusion Flowsheet 11. PATIENT EDUCATION Teaching- 12. DR. ORDERS 13. NURSES STATION Nursing Admission Assessments: Patient Care Plans: 24-hour Nursing Assessment Nurses' Bedside Notes Nursing Flowsheets Rhythm Strips Vital Signs Record Bowel Program I & O record Graphic Notes Diabetic Record IV Solution Record Medication Records (daily & weekly) Clothing and Valuables Release of Side Rails AMA Forms 14. MISCELLANEOUS Newborn Authorizations and permits Paternity Forms Consent for SS# Alternate Referral Form Consent Forms: Photographic Support Services Referral Equipment Prescription Form Copies from other health care providers Ability to pay program request Consent forms for Release of Information Notice of Privacy Practices Acknowledgement of Receipt Survey of New Parents Medicare Hospital Beneficiary Notice of Non-coverage (copy) 14 of 14 Copyright California Health Information Association, AHIMA affiliate 14