AMBULATORY ELECTRONIC MEDICAL RECORDS MANAGEMENT

Transcription

1 2/28/2014 Page 1 f 18 AMBULATORY ELECTRONIC MEDICAL RECORDS MANAGEMENT 1 Purpse The purpse f this plicy is t standardize rles, respnsibilities, and principles fr the Ambulatry Electrnic medical recrd Effective January 1, 2006, the Ambulatry Electrnic Medical Recrd is the primary Ambulatry Medical Recrd; the paper medical recrd is the histrical recrd Refer t Appendix A In accrdance with rganizatinal, regulatry, accrediting, and billing requirements, this plicy shall serve the fllwing purpses: 11 Require all practitiners t use the Ambulatry Electrnic Medical Recrd as the primary surce fr all clinical dcumentatin Refer t Sectin Standardize the access t Ambulatry Electrnic Medical Recrds Refer t Sectin Standardize dcumentatin f in the Ambulatry Electrnic Medical Recrd Refer t Sectin 423 Prvide standards fr dcumenting in the Ambulatry Electrnic Medical Recrd Making dcumentatin crrectins in the Ambulatry Electrnic Medical Recrd Prvide guidelines t avid indiscriminately cpying and pasting anther clinician s prgress nte, discharge summary, electrnic mail cmmunicatin, and redundant infrmatin prvided in ther parts f the Ambulatry Electrnic Medical recrd Prvide guidelines fr eliminating the use f ptentially cnfusing medically-related abbreviatins in dcumentatin Prvide guidelines fr electrnic signature and authenticatin Prvide guidelines fr the timely cmpletin f the Ambulatry Electrnic Medical Recrd 14 Prvide guidelines fr cmmunicating with patients Refer t Sectin 424

2 2/28/2014 Page 2 f 18 Prvide guidelines fr cmmunicatin via kprg bth inside and utside f the Ambulatry Electrnic Medical Recrd Prvide guidelines fr telephne messaging between practitiners and patients 15 Prvide guidelines t ensure that all pen encunters are clsed prir t a practitiner s planned r unplanned departure as well as in the event an encunter is fund t be left pen after a nursing emplyee transfers t anther department r is n lnger emplyed at KP Refer t Sectin Prvide infrmatin n mnitring the Ambulatry Electrnic Medical Recrd Refer t Sectin Prvide a frm fr Ambulatry Medical Recrd dcumentatin when the Ambulatry Electrnic Medical Recrd is unavailable (dwntime) Refer t Sectin Scpe This plicy applies t all authrized emplyees, students, residents and fellws within the Hawaii Regin, the Ambulatry Surgical Center (ASC), and its vendrs and cntractrs, wh are respnsible fr dcumentatin and have been identified as users f the Ambulatry Electrnic Medical Recrd 3 Definitins Ambulatry Electrnic Medical Recrd Electrnically stred utpatient medical recrds, including all surgeries and care that d nt invlve hspital r hspital-based services APN Ambulatry Prgress Nte (frm) Clinic Infrmatin Systems (CIS) A frmerly used electrnic medical recrd Cmplete and accurate dcumentatin Dcumentatin that supprts the diagnsis and the medical necessity fr services prvided Delinquent Medical Recrd Any encunter nt cmpleted and clsed by end f day DPN Dwntime Prgress Nte (frm) Encunter Mechanism by which direct r indirect patient care is dcumented in the Ambulatry Electrnic Medical Recrd Encunter Types include, but are nt limited t: Direct Encunters (face-t-face):

3 2/28/2014 Page 3 f 18 Allied Health/Nurse Visit Grup Visit OB Office Visit Office Visit Prcedure Indirect encunters (patient nt physically present): Letter Message Orders nly Patient Refill Scheduled Telephne Telephne Scanned dcument Encunter Prvider The Ambulatry Electrnic Medical Recrd term fr the scheduled practitiner r allied health prfessinal wh gives care and services t the patient Full Functinality User Ambulatry Electrnic Medical Recrd user with security access t read, write, and rder in the Ambulatry Electrnic Medical Recrd HIPAA Health Insurance Prtability and Accuntability Act f 1996 HPMG Hawaii Permanente Medical Grup Ambulatry Electrnic Medical Recrd Electrnic dcumentatin tl fr patient care in the utpatient clinics This is a cmprehensive system that will supprt the cllectin, retentin, management and review f the data needed t effectively track and manage care Legal Name A persn s current name that can be validated with fficial federal r state dcumentatin and establishes the identity f the persn Examples f dcuments in rder f pririty: Official dcument indicating legal name r a name change, ie birth certificate, marriage certificate, adptin papers, certificate f legal name change, divrce decree, Military ID, State ID Scial security dcuments/federal tax frms Prfessinal License (if this name is different than abve legal name indicate with nte in files) Natinal Cmmittee n Quality Assurance (NCQA) An accreditatin rganizatin

4 2/28/2014 Page 4 f 18 Nursing Assistive Persnnel Authrized nursing persnnel wh assist licensed nursing staff in cmpleting delegated nursing tasks r medical tasks as rdered by a practitiner and as permitted by law [eg Medical Assistants (MA), Ophthalmlgy Assistants (OA), Emergency Department Technician (ED TECH), Hspital Aides (HA), Nursing Assistants (NA), Health Aides, ther technicians (TECH), and Ward Clerks (WC)] Ambulatry Medical Recrd A legal recrd f ambulatry care and services fr an individual either paper r electrnic subject t a variety f statutes and regulatry rules that ften define the use, disclsure, care, handling, and retentin f Prtected Health Infrmatin (PHI) Refer t Legal Medical Recrd Plicy The cmplete and cmprehensive Ambulatry Medical Recrd is cmprised f the fllwing: Ambulatry Electrnic Medical Recrd Paper medical recrd Overdue Message When MD is wrking, any kprg message nt respnded t within tw business days, excluding week-ends and hlidays When MD is n leave, any kprg message nt reviewed within tw business days, excluding week-ends and hlidays Practitiner - The term Practitiner refers cllectively t Licensed Independent Practitiners and Allied Health Practitiner Licensed Independent Practitiner (LIP) - an individual permitted by law and by KPHI t prvide patient care services t members withut directin r supervisin, within the scpe f his r her license, and in accrdance with individually granted Clinical Privileges Licensed Independent Practitiner includes Medical Dctrs, Dctrs f Ostepathy, Dctrs f Dental Surgery, Dctrs f Dental Medicine, and Dctrs f Pdiatric Medicine licensed t practice in Hawaii Allied Health Practitiner (AHP) a health care prfessinal, ther than a Licensed Independent Practitiner (LIP), wh exercises independent judgment within the areas f his r her prfessinal cmpetence and the limits established by KPHI, the Prfessinal Staff f a Kaiser Fundatin Hspital, and applicable law The fllwing categries f Practitiners shall be cnsidered Allied Health Practitiners when exercising the independent judgment in the care f patients described abve: Physician Assistants, Certified Registered Nurse Anesthetists, Registered Nurses, Dietitians, Certified Nurse Midwives, Nurse Practitiners, Clinical Psychlgists, Licensed Clinical Scial Wrkers, Licensed Marriage and Family Therapists and Optmetrists, and thers, as required by state laws, regulatry and/r accreditatin bdies

5 2/28/2014 Page 5 f 18 RNHO Reginal New Hire Orientatin TJC The Jint Cmmissin 4 Plicy 41 Plicy Statement This plicy shall prvide directin t all users f the Ambulatry Electrnic Medical Recrd t ensure current, detailed, accurate, cmplete and cnsistent dcumentatin f patient care that: Permits effective and cnfidential patient care and quality review Supprts rganizatinal, regulatry, accrediting, cding and billing requirements The ambulatry medical recrd is rganized by encunter types which cntain dcumentatin fields fr face-t-face and nn face-t-face encunters 42 Standards The Hawaii Regin establishes ambulatry medical recrd standards t facilitate cmmunicatin, crdinatin, and cntinuity f care and t prmte efficient and effective treatment 421 Ambulatry Electrnic Medical Recrd Requirement Unless the Ambulatry Electrnic Medical Recrd is dwn r unavailable, all full functinality practitiners wh have been trained t use the Ambulatry Electrnic Medical Recrd shall be required t use the Ambulatry Electrnic Medical Recrd fr all encunter dcumentatin, rders, and prescriptins, in accrdance with established wrkflws Practitiners wh have nt been trained t use the Ambulatry Electrnic Medical Recrd fr dcumentatin and rder entry shall be required t use the Ambulatry Prgress Nte (APN) frm fr dcumentatin f all encunters In instances where the Ambulatry Electrnic Medical Recrd des nt prvide the apprpriate dcumentatin mechanism, exceptins t dcumentatin n the apprpriate and apprved chart frm shall apply 422 Access t Ambulatry Electrnic Medical Recrd Systems

6 2/28/2014 Page 6 f 18 All Hawaii Regin emplyees shall have access t the apprpriate and minimum infrmatin required t cmplete their jb duties using the Ambulatry Electrnic Medical Recrd prcesses by the start date f wrk 4221 Upn creatin r mdificatin f jb descriptins, jb accuntabilities shall be aligned with the minimum necessary security access and functinal access requirements 4222 T btain Ambulatry Electrnic Medical Recrd access, all newly hired emplyees shall: Have their legal name ascertained and recrded in the system alng with the ther required infrmatin, and Cmplete Reginal New Hire Orientatin (RNHO) in the required timeframe 4223 Upn arrival at the jb site fr rientatin, all emplyees shall have apprpriately assigned Ambulatry Electrnic Medical Recrd access t cmplete their jb respnsibilities Emplyees wh by exceptin use alternative learning methds t meet accreditatin and HIPAA and ther regulatry rientatin requirements shall attend RNHO Technical training t btain systems access New hires awaiting credentialing shall be assigned a prfile apprpriate t their status with functinally limited access until credentialing is btained Access shall be adjusted upn ntice f credentialing 4224 Upn change f emplyee status as in terminatin, resignatin, transfer, r additin f ther psitin, infrmatin systems shall be readjusted in a defined timeframe Terminatins and resignatins must be cmpleted within 48 hurs f ntificatin per SOX plicy Access mdificatins fr transfers and multi-psitin staff will be cmpleted within 72 hurs pst status change SOX apprvals frm Business Applicatin Owners may be required

7 2/28/2014 Page 7 f Dcumentatin Requirements fr Ambulatry Electrnic Medical Recrd Patient Encunters Any practitiner wh dcuments health care infrmatin in an Ambulatry Electrnic Medical Recrd encunter shall adhere t the guidelines defined by scpe f practice, security classificatin and jb descriptin in prviding care fr patients The Encunter Prvider shall be respnsible fr versight f all dcumentatin in the encunter, which includes clinical dcumentatin by ther users within that encunter The Encunter Prvider and the signing/clsing prvider shall be the same Exceptin: When rders are transmitted by Nursing Assistive Persnnel (NAP) in an encunter under the NAP s name, the Practitiner wh authrized thse rders must clse the NAP s encunter, authenticating any rders within that encunter 4231 Ambulatry Electrnic Medical Recrd Dcumentatin Standards Dcumentatin in practitiner encunters shall adhere t the Ambulatry Electrnic Medical Recrds Dcumentatin Standards Refer t Appendix B 4232 Ambulatry Electrnic Medical Recrd Dcumentatin Crrectins The authr shall be respnsible fr making timely crrectins t dcumentatin errrs in the Ambulatry Electrnic Medical Recrd The cntent can be crrected by an authrized practitiner under certain circumstances (Refer t Sectin 428) 4233 Ambulatry Electrnic Medical Recrd Cpy and Pasting Clinicians dcumenting in the Ambulatry Electrnic Medical Recrd must avid indiscriminately cpying and pasting anther clinician s prgress nte, discharge summary, electrnic mail cmmunicatin, and redundant infrmatin prvided in ther parts f the health recrd

8 2/28/2014 Page 8 f 18 If all r part f an entry made by anther clinician is used, the clinician making the entry takes respnsibility fr the accuracy f the entry and thrugh their authenticatin f the infrmatin affirms that it is relevant and apprpriate t the episde f care (See Utilizatin f Cpy/Paste Functinality fr Dcumentatin fr Hspital and Hspital-based services, Plicy # ) 4234 Ambulatry Electrnic Medical Recrd D Nt Use Abbreviatins All practitiners must fllw D Nt Use Abbreviatin plicy (See D Nt Use Abbreviatins fr Medical Recrds Dcumentatin Plicy # , and link t list n Intranet Hme Page / Business Links / Abbreviatins List) 4235 Ambulatry Electrnic Medical Recrd Dcumentatin Signature Requirements All Ambulatry Electrnic Medical Recrd dcumentatin must be electrnically authenticated at the time f entry (See Electrnic Signature and Authenticatin Plicy # ) 4236 Ambulatry Electrnic Medical Recrd Timely Cmpletin Encunters, whether in persn, by telephne, r by secured messaging, shall be dcumented and cmpleted at the time f the encunter, r by end f day Practitiners shall cmplete all delinquent recrds pen beynd the fllwing threshld by the required date as apprpriate: 10 r mre encunters pen fr mre than 7 days Any encunters pen fr mre than 14 days Delinquent recrds shall be mnitred n an nging basis and addressed accrdingly At the apprpriate prfessinal r peratinal chief s discretin and in accrdance with HPMG Plicy time fr cmpletins might include: Own time Other effective slutin as apprved by the prfessinal r peratinal chief

9 2/28/2014 Page 9 f 18 Required administrative leave, withut pay 424 Cmmunicatin Requirements fr the Ambulatry Electrnic Medical Recrd Address patients with the crrect title (ie Miss, Mrs, Ms, Mr) and use last names unless the patient indicates he/she wishes t be called by first name, nickname, r pseudnym D nt refer t patients by nly their last name r their medical cnditins Never use terms that belittle a patient s dignity, such as sweetie r darling Cmmunicatin shuld nt be used fr urgent cmmunicatins (eg, regarding sudden r substantive changes in the patient's health) Avid anger, sarcasm, harsh criticism, and libelus references t third parties in messages Never frward patient-identifiable infrmatin t a third party withut the patient s express permissin Cmmunicatin within the Ambulatry Electrnic Medical Recrd When feasible, cmmunicatin between prviders and patients shuld be dne using Ambulatry Electrnic Medical Recrd functinality This ensures that all clinically relevant messages and respnses will be dcumented in the medical recrd, and that respnses t patients are nt misdirected r therwise becme available t unintended parties Practitiners shall review and if apprpriate respnd t kprg message within tw business days, excluding weekends and hlidays Overdue messages shall be mnitred n an nging basis and addressed accrdingly

10 2/28/2014 Page 10 f 18 At the apprpriate prfessinal r peratinal chiefs discretin, time fr cmpleting verdue messages will be: Own time Other effective slutin as apprved by the prfessinal r peratinal chief Required administrative leave, withut pay Cmmunicatin utside the Ambulatry Electrnic Medical Recrd If, in the prvider s prfessinal judgment, a cmmunicatin must be made with a patient utside the Ambulatry Electrnic Medical Recrd, any such cmmunicatins that cntain clinically relevant infrmatin must be retained and stred within the patient s health recrds If such cmmunicatin is unencrypted, the prvider must advise the patient abut the risk and dcument the individual s stated preference t the unencrypted cmmunicatin (See Electrnic Cmmunicatin Functins Plicy # HIIS010, Sectin 1025) 4242 Telephne messaging Between Practitiners and Patients Practitiners will leave a minimum f infrmatin unless a written request frm patient is btained prir t leaving telephne messages cntaining PHI in a vice mail message, n an answering machine, r with anyne answering the telephne (See Practitiner/Staff and Patient Detailed Telephne Messaging Plicy # ) 425 Practitiners Leaving the and Nursing emplyees wh transfer t anther department r are n lnger emplyed at KP Upn ntificatin f the practitiner s departure:

11 2/28/2014 Page 11 f 18 The Supervisr, Manager, r Chief shall be accuntable t ntify Human Resurces and HPMG when a practitiner is leaving KP emplyment The apprpriate prfessinal r peratinal chief shall assign respnsibility fr inbasket management f the terminating user Planned Departure Upn ntificatin f a planned practitiner departure, the immediate prfessinal r peratinal chief shall cmmunicate the expectatin fr all pen encunters t be cmpleted and clsed, all dictatins authenticated, and all medicatin verbal rders csigned prir t departure (See 4224) Unplanned Departure Open encunters fllwing a practitiner s unplanned departure shall be cmpleted by an assigned practitiner with same/higher credentials, as determined by the apprpriate prfessinal r peratinal chief When crrectin f dcumentatin is required (ie per HIPAA) t be cmpleted during a practitiner s absence, the immediate prfessinal r peratinal chief may perfrm the apprpriate crrectin in cllabratin with Medical Recrds Administratin, the Electrnic Medical Recrd Security team, and Release f Infrmatin Departments The Nursing Supervisr/Manager is authrized and shall be respnsible fr the clsing f pen encunters generated in their department(s) by nursing emplyees wh have transferred t anther department r are n lnger emplyed at KP 426 Mnitring 4261 Mnitring Dcumentatin excluding Hspital Service Departments (HSD s) Cmplete and apprpriate clinical dcumentatin Standard: 95% r greater f all face-t-face billable encunters shall have dcumentatin that supprts the services prvided Timely cmpletin f ambulatry patient

12 2/28/2014 Page 12 f 18 Standard: Timely Cmpletin shuld be 90% r greater Delinquency Rate Threshld: N higher than10% An pen encunter reprt shall be run weekly t identify practitiners wh have delinquent recrds that need t be cmpleted and clsed Rutine audit reprts as apprpriate shall be made available t Clinic Managers and/r Physician Chiefs wh are accuntable t initiate crrective actin 4292 Mnitring System Availability Standard: System shall be available 997% 24 hurs a day, 7 days a week, and 365 days a year 427 Dwntime 5 Respnsibilities In the event that the Ambulatry Electrnic Medical Recrd is dwn r unavailable: Lcal administratin in cllabratin with the Ambulatry Electrnic Medical Recrd administratin, shall invke the dwntime prcedures Refer t KPHC Dwntime (Suite) psted n MyHelp All practitiners, whether r nt they currently dcument in the Ambulatry Electrnic Medical Recrd, shall be required t use the apprpriate Dwntime Prgress Nte (DPN) frm The apprpriate frm shall be cmpleted as sn as pssible after the visit ccurs, and n later than 24 hurs after the visit The Ambulatry Medical Recrd Business Owner and the Medical Recrd Physician Owner shall be respnsible t ensure physician and nn-physician cmpliance with current, detailed, accurate, cmplete and cnsistent dcumentatin f the Ambulatry Medical Recrd The Ambulatry Medical Recrd Business Owner shall be the designated custdian f the Ambulatry Electrnic health recrd

13 2/28/2014 Page 13 f 18 KP Infrmatin Technlgy and the Ambulatry Electrnic Medical Recrd Clinical Applicatins Manager shall be respnsible t ensure adherence t apprpriate Ambulatry Electrnic Medical Recrd systems access guidelines Clinic Managers and Physician Chiefs shall be respnsible fr adherence t the prvisins f this plicy 6 Maintenance This plicy shall be reviewed at least every three (3) years r mre ften as required and revised as necessary 7 References Center fr Medicare and Medicaid Services (CMS) Cde f Federal Regulatins 42 CFR (b)(4)(ii) Cpy/Paste Functinality fr Dcumentatin fr Hspital and Hspital-Based Services Plicy Dcumentatin When the Ambulatry Electrnic Health Recrd is Unavailable Prcedure D Nt Use Abbreviatins fr Medical Recrds Dcumentatin Plicy Replaced by User Access Management Plicy # HIIS012 Electrnic Signature and Authenticatin Plicy Replaced by Electrnic Cmmunicatin Functins Plicy # HIIS010 Hawaii Dwntime Prcedures Outpatient versin 1 40 Hawaii Revised Statutes and Federal Regulatins KP HI Dcumentatin Standards KP HealthCnnect Online Guiding Principles ( ) Legal Medical Recrd Plicy ( ) MedQuest Sectin 12 Medical Recrd Retentin Plicy ( ) Natinal Cmmittee n Quality Assurance (NCQA) Practitiner/Staff and Patient Detailed Telephne Messaging Plicy Implementatin A Effective Date

14 2/28/2014 Page 14 f 18 This plicy becmes in effect upn apprval f apprving authrities and shall be published and disseminated within 30 days B Distributin Upn apprval, this plicy shall be distributed t all prcess stakehlders and the affected entities and departments As applicable, affected entities, departments, and individuals may prepare and implement prcedures cnsistent with this plicy and as necessary cnduct apprpriate educatin t assure cnsistent and unifrm implementatin This plicy is accessible n the KP Hawaii Regin intranet

15 2/28/2014 Page 15 f 18 9 Endrsement and Apprval Cntact Persn: Jeniffer Zimmerman Manager, Medical Recrds - Clinic Reviewed By: Wil Kuke Directr Clinical Services Date: 10/31/2013 Endrsed By: Maile Hwick, RN KPHC Clinical Applicatins Manager Winnie Sze, MSN, APRN-Rx, CDE, CHC Supervisr fr Ambulatry Nursing Practice & Clinic Cmpliance leader Rxanne Mrey Manager, KPHC Build, Security and Supprt Paulette Nakamura, APRN Ambulatry Nursing Practice Laura Sherrill Privacy & Security Officer Benjamin Tamura, MD Assciate Medical Directr, Primary Care/Internal Medicine and PIC, Primary Care Clinics Ambulatry Medical Recrd Physician Owner Date: 3/7/2014 Date: 3/7/2014 Date: 3/7/2014 Date: 3/7/2014 Date: 2/28/2014 Date: 3/9/2014 Apprved By: Quality Cmmittee Date: 4/10/2014 Next Review Date: 2/2017 Replaces: AMR-P1: Autmated Medical Recrds Management 10 Appendices Appendix A: Cmpsitin f the Ambulatry Electrnic Medical Recrd Appendix B: Ambulatry Electrnic Medical Recrds Dcumentatin Standards

16 2/28/2014 Page 16 f 18 APPENDIX A COMPOSITION OF THE AMBULATORY ELECTRONIC MEDICAL RECORD The Ambulatry Electrnic Medical Recrd is cmprised f the fllwing: TYPE DATE RANGE 1 Paper Medical Recrd Nvember 1958 t Nvember Clinical Infrmatin System (CIS) Octber 2001 thrugh December 19, KP HealthCnnect Ambulatry April 18, 2004 t Present

17 2/28/2014 Page 17 f 18 APPENDIX B: AMBULATORY MEDICAL RECORDS DOCUMENTATION STANDARDS

18 2/28/2014 Page 18 f 18