AHIMA Publishes LTC Document Guidelines

Vol. 11 •Issue 19 • Page 8
AHIMA Publishes LTC Document Guidelines * AHIMA Publishes LTC Document Guidelines

The American Health Information Management Association (AHIMA) has published health information practice and documentation guidelines to address the long-term care (LTC) industry’s need for complete and accurate clinical record documentation. These guidelines are designed as a resource for health information management (HIM) professionals and health care organizations on the role of the health information practitioner. They also provide guidelines for establishing and maintaining health information systems, as well as documentation guidelines specific to LTC.

“There are few resources available to HIM professionals in the LTC industry,” states Michelle Dougherty, RHIA, AHIMA’s professional practice manager and LTC Taskforce coordinator and project manager. “AHIMA’s ‘LTC Health Information Practice and Documentation Guidelines’ pulls together legal documentation guidelines and addresses the basic requirements for documentation in the LTC record.”

In addition, AHIMA’s “LTC Health Information Practice and Documentation Guidelines”:

• Provide an outline on the recommended qualifications, responsibilities and functions that would be performed by health information consultants, credentialed health information practitioners working in an LTC facility, non-credentialed practitioner working in an LTC facility and a health unit coordinator.

• Establish a baseline for the systems that should be in place for maintaining the record systems in an LTC facility.

• Review the legal documentation standards for entries in and maintaining the medical record–addressing the purpose of the medical record and definition of the legal medical record; legal documentation standards that apply to medical records; and proper methods for handling errors, omissions, addendums and late entries.

• Create a foundation for documentation by addressing the minimum content as required by federal regulation for LTC facilities and fundamental practice standards.

• Provide a checklist of HIM policy and procedures that may be included in a manual for health information services.

“LTC Health Information Practice and Documentation Guidelines” is available free of charge at AHIMA’s Web site at www.ahima.org/infocenter/guidelines/ltcs/index.html. These guidelines were developed by an AHIMA taskforce comprising of HIM professionals and specialists with key areas of expertise. They are intended for use by health care provider organizations and HIM professionals to provide assistance and direction in developing and maintaining health information systems that meet professional practice standards. The guidelines, samples and examples can be used in development of facility/organization systems, policies and procedures without obtaining special copyright permission.


HI&T Week Planning Kit Available Now

Take time to celebrate our contributions to the health care industry during National Health Information and Technology (HI&T) Week, November 4-10. This year’s theme is “Celebrate, Innovate, Educate.” To help you get started with your efforts, visit www.ahima.org/hitweek to access your free HI&T Week Planning Kit online. AHIMA’s free HI&T Week planning kit includes: a fact sheet; event ideas; information about commemorative merchandise; a press release; a logo sheet; and a presentation on timely topics HIM professionals can adapt and use.


RHIA/RHIT Application Deadline Extension

Good news for those individuals wishing to take the RHIA or RHIT certification exams during the fourth quarter, 2001. The deadline for acceptance of applications for these exams has been extended from September 15th to October 15th. Candidates registering for these exams must have their registration forms and appropriate transcripts to AHIMA post-marked no later than October 15th. Approved applications received for the forth quarter will be valid through December 23rd. For additional information, visit www.ahima.org/certification/.