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Follow these tips for completing the patient record

HIM Connection, July 4, 2006

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Follow these tips for completing the patient record

Depending on your organization, HIM, patient-care services staff, or even volunteers, are responsible for returning discharged records to the HIM department. To help the department complete its functions, these records should arrive no later than one day after a service or discharge. The following describes best practices for dealing with inpatient, outpatient surgery, and outpatient diagnostic test records.

Inpatient record
Assign HIM staff to retrieve records in the late evening or night hours, a time when clinical staff probably are not using the records. For inpatient records, staff should have a discharge census by patient-care area. Use this census-which should be alphabetized by patient-care area-to check off and verify all retrieved records. Train your HIM employees to immediately query the patient-care staff if one or more records are missing, rather than waiting until after leaving the location.

Outpatient surgery record
All types of outpatient records are more challenging. Ambulatory surgery and endoscopy departments often prefer to hold their records to perform postsurgery follow-up, so consider

• using a two-part form for the critical clinical information that allows the outpatient area to have the information it needs, yet allows HIM to have access to the complete record for coding.

• additional loose material (e.g., postsurgical follow-up) to place with the patient's record. One option is to pick up the records at the end of the surgery day and code the records that evening. By doing so, the records are available for the emergency department (ED) should that patient have an untoward event after discharge from the outpatient area. Early the next morning, return the records to the outpatient surgical area so the staff can perform postsurgical follow-up activities. This method maintains the unbilled records at an acceptable level and reduces the handling of the postsurgical follow-up documentation or loose materials, but requires extra labor to return the records and retrieve the records at the end of the next day.

• those surgeons and gastrointestinal physicians who do not routinely dictate immediately after surgery or procedure. The timely dictation and transcription of pathology reports are equally important and necessary for the coding process. Delaying the pickup of outpatient surgery records until the afternoon of the day after surgery allows sufficient time for the reports to be transcribed and placed in the record and eliminates record-return efforts and follow-up, but restricts access by the ED if an emergency arises the evening of the surgery. Therefore, it may be necessary for HIM personnel or the evening/night patient-care supervisor to have access to the office or records cabinet.

Outpatient diagnostic tests
The growth in outpatient services has been steady since the advent of diagnosis-related groups in the 1980s-and piecemeal outpatient diagnostic test records are one of HIM's greatest challenges. Although coding these records may be somewhat easier than coding inpatient records, the compliance aspects are as important. Coding without an order is inappropriate, yet allowing accounts awaiting reports to accumulate can become a nightmare for both HIM and patient financial services. How does HIM get its arms around outpatient records? For HIM departments that handle the paper, sorting the records from numerous diagnostic-service areas can be challenging. To make the process run smoother try

• setting up tubs with hanging files by date of service.

• filing the paperwork based on the date of service.

• removing (after a set number of days) the contents of one date and marrying all documents for the same patient.

• comparing the documents to a service-inventory report.

• giving to coding staff.

• filing documents.

Editor's Note: This article was adapted from HCPro, Inc.'s book More with Less: Best Practices for HIM Directors, by Rose T. Dunn, RHIA, CPA, FACHE, FHFMA. For more information or to order, go to www.hcmarketplace.com, or call 877/727-1728.

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