Long Term Care ICD-10-CM
Implementation/Closed Clinical
Record Auditing
Presented By
Stephanie Sakson, RHIA
May 23, 2016
ICD-10-CM Implementation
• AHIMA’s ICD-10 Coding
Guidance for Long-Term
Care Facilities
• Importance of
– Keeping Each Resident’s
Active Diagnosis List
Current
• Ex. Pneumonia, Aphasia
– Identifying Who Will Be
Responsible for ICD-10-CM
Code Assignment
http://bok.ahima.org/doc?oi
d=107574#.VyaKxfkrLIU
ICD-10 CODING
• Use of Z Codes in LTC
• Different Way of Coding
Traumatic & NonTraumatic Fractures
• Sequencing of
Diagnoses When the
Resident Returns from
Hospitalization
Closed Clinical Record Audit
• Ensures Compliance with Regulations
• Can Identify Areas of Non-Compliance
• Can Serve as a Quality Improvement Tool
AHIMA’S Long Term Care
Documentation Guidelines
• Addresses Federal LTC
Documentation Guidelines
• Should be Shared with LTC
HIM Staff
• Great Resource for LTC
Policies & Procedures, as
well as Job Descriptions
http://ahimaltcguidelin
es.pbworks.com/w/file/
fetch/66945303/LTCGui
delines_complete.pdf
PA Department of Health
Regulations
• Regulation 211.5 – Clinical Records
• Remember to Reference PA Department of
Health Interpretive Guidelines
Closed Clinical Record Audit
Criteria
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Physician Discharge Summary
Interdisciplinary Discharge Summary
Inventory Sheet
Medication Disposition
Physician’s Orders
Discharge Order
Nursing Discharge Documentation
Mortician Receipt
Physician Discharge Summary
• Required on all Discharges
• Required Elements:
- Admission & Discharge
Dates
- Summary of Care
- Final Diagnoses
- Prognosis if Discharged
Alive
- Cause of Death if Expired
- Physician/Physician
Extender Signature
& Date
Interdisciplinary Discharge Plan
• Required for all Planned Discharges
• Should be Completed by all Disciplines Prior to
Resident’s Discharge
• Resident/Responsible Party Must Sign
• Copy Given to Resident/Responsible Party at
the time of Discharge
• Discharge Instructions Must be in Layman’s
Terms
Inventory Sheet
• Must be signed & dated
by Resident/
Responsible Party upon
– Admission
– Discharge
Medication Disposition
• Nurse must:
– Document number of each prescribed medications
remaining as well as its disposition
• Ex. Coumadin - 4 returned to pharmacy
– Initial & date
• Recommendation:
– HIM staff check for this documentation as soon as
chart is retrieved from nursing unit
Physician’s Orders
• All telephone orders are
signed & dated by the
physician
• All monthly
renewals/recaps of orders
are signed by physician
Discharge Order
• Obtained for Day of Discharge
• Must include Discharge Destination
• For Expired Residents, Order to Release Body
to Funeral Home Must be Present
• If Medications are sent Home or to Another
Facility, this must be included in Order
Nursing Discharge Documentation
• Documentation leading to resident’s discharge
or death
• Note at the Time of Discharge
• For Deaths, Nurses Notes Should Identify
Physician & Family Notification
• Per Department of Health Regulations (211.4),
the Name of the Person Notified of Resident’s
Death Must be Present in the Resident’s
Clinical Record
Mortician Receipt
Mortician Receipt Should
Be Present on the Clinical
Records of All Residents
Who Have Expired.
Mortician Receipt is a
Federal Requirement.
Closed Clinical Record Audit Form
Developed by Stephanie Sakson
Ensuring Accurate Documentation
that Complies with Regulations
Will Go A Long Way In Helping Your
Facility Achieve Success
Questions
Contact Information
• Email: [email protected]
• Phone: (570) 489-2514
Thank you 