RHIT Exam

This chapter walks through the documents found in a typical inpatient hospital record, separated into administrative data and clinical data, and gives the timing rules that the RHIT exam tests most often.

Administrative data identify the patient and support the business side of the encounter. The face sheet (also called the registration record or admission record) is usually the first page of the record. It holds demographics (name, date of birth, sex, address, phone), the medical record number (MRN), the account or encounter number, insurance and guarantor information, admission date and time, attending physician, admitting diagnosis, and at discharge the discharge date, disposition and final coded diagnoses and procedures.

Other administrative documents include:

Consent forms: a general consent to treatment signed at admission, plus informed consent for specific procedures (surgery, anesthesia, blood transfusion, research participation). Informed consent means the provider explained the nature of the procedure, risks, benefits and alternatives; the physician performing the procedure is responsible for obtaining it, even if a nurse witnesses the signature.

Advance directives: written instructions about future care if the patient cannot speak for himself or herself, such as a living will (what treatment the patient does or does not want) and a durable power of attorney for health care (who will decide for the patient).

Notice of Privacy Practices acknowledgment: written acknowledgment that the patient received the hospital's Notice of Privacy Practices, or documentation of a good-faith effort to obtain it.

Property and valuables lists, patient rights acknowledgments, and the Important Message from Medicare for Medicare inpatients.

The Patient Self-Determination Act (PSDA) is a federal law that applies to hospitals, skilled nursing facilities, home health agencies, hospices and certain health plans that participate in Medicare or Medicaid. At admission or enrollment the organization must give adult patients written information about their right under state law to accept or refuse treatment and to make advance directives, ask whether the patient has an advance directive, document the answer in the record, and educate staff and the community. The organization may not condition care on whether a patient has an advance directive.

Clinical data describe the patient's condition and the care given. The following table summarizes the key clinical documents and their commonly tested timing rules, which come from the Medicare Conditions of Participation (CoP) for hospitals and from Joint Commission standards. Medical staff bylaws and state law may set stricter time frames.

The H&P documents the patient's history and the physician's initial physical examination. It must be completed and documented by a physician, oral and maxillofacial surgeon, or other qualified licensed practitioner allowed by state law and medical staff bylaws.

The timing rule is the single most tested fact in this chapter: the H&P must be done no more than 30 days before admission or within 24 hours after admission (or registration), and in every case before surgery or a procedure requiring anesthesia services. When the H&P was done within 30 days before admission, an update note documenting an exam for any changes in the patient's condition must be completed within 24 hours after admission and before surgery.

HIM Scenario: Darnell Hughes saw his surgeon in the office 18 days before an elective knee replacement, and the office H&P was scanned into the hospital record. On the morning of surgery, the HIM record-completion technician sees no update note. Because the H&P is within 30 days but lacks an update, the record is deficient. Policy at most hospitals is to stop the case until the update is documented, so the surgical services staff are notified before the patient goes to the operating room.

Physician orders direct care. Orders entered through computerized provider order entry (CPOE) are authenticated by the ordering practitioner's login and electronic signature. Verbal orders (given in person) and telephone orders must be accepted only by personnel authorized by policy and state law, written down and read back for verification, and then authenticated by the ordering practitioner (or another practitioner responsible for the patient and authorized to write orders) within the time frame set by state law and hospital policy. Many hospitals use 48 hours as their standard, but the exact time varies by state and policy.

Progress notes record the patient's course in the hospital. Physicians, nurses, therapists, dietitians and other clinicians write progress notes. The frequency depends on the patient's condition and medical staff rules; most hospitals expect a physician progress note at least daily for acute inpatients.

A consultation report is written by a consultant (another practitioner asked to give an opinion). It includes the reason for the consult, the consultant's review of the record, examination findings, opinion and recommendations, and is signed by the consultant. The attending physician's request for consultation is usually entered as an order.

The operative report must be written or dictated immediately following surgery and authenticated by the surgeon. It describes the preoperative and postoperative diagnoses, the name of the primary surgeon and assistants, the procedure performed, findings, specimens removed, estimated blood loss and any complications.

When the full operative report cannot be placed in the record immediately (for example, while dictation is being transcribed), a brief operative note (also called an immediate postoperative note) must be entered immediately after surgery and before the patient is transferred to the next level of care. It records the surgeon and assistants, procedure, findings, estimated blood loss, specimens and postoperative diagnosis so the next caregivers know what happened.

Anesthesia documentation includes the pre-anesthesia evaluation (completed within 48 hours before surgery by a practitioner qualified to administer anesthesia), the intraoperative anesthesia record (agents, doses, vital signs, fluids, events), and the post-anesthesia evaluation (completed and documented no later than 48 hours after surgery). The post-anesthesia evaluation typically documents respiratory function, cardiovascular function, mental status, temperature, pain, nausea and vomiting, and hydration.

The pathology report describes tissue removed during surgery or other procedures, with a gross description (what the specimen looks like to the eye) and microscopic description, ending in a pathologic diagnosis. It is authenticated by the pathologist. Some items, such as certain foreign bodies or teeth, may be exempt from pathology examination under medical staff rules.

Nursing documentation includes the nursing admission assessment, care plans, flow sheets (vital signs, intake and output), nursing progress notes and patient education records. The medication administration record (MAR), usually electronic (eMAR), records every medication given: drug, dose, route, time and the person who gave it. Missed or refused doses are also documented.

The discharge summary concludes the inpatient stay. It summarizes the reason for hospitalization, significant findings, procedures performed and treatment given, the patient's condition at discharge, instructions to the patient and family (medications, diet, activity, follow-up care), and the final diagnoses. It is written by the attending physician (or another practitioner authorized by the medical staff) and authenticated.

A final progress note may replace a full discharge summary for patients hospitalized less than 48 hours with only minor problems or uncomplicated conditions, for normal newborn infants, and for uncomplicated obstetrical deliveries, when allowed by hospital policy and medical staff rules. The final progress note must still document the outcome of hospitalization, disposition and provisions for follow-up care.

When an autopsy is performed, the autopsy report documents the pathologist's findings. Provisional anatomic diagnoses are commonly recorded within 3 days, and the complete report is commonly required within 60 days, according to medical staff rules and accreditation practice. Autopsy consent from the legal next of kin (or a legal order from a medical examiner or coroner) must be part of the record.

• The face sheet, consents, advance directive documentation and the Notice of Privacy Practices acknowledgment are administrative data; reports describing care are clinical data.
• The PSDA requires informing adult patients of advance directive rights, asking, documenting and not discriminating.
• The H&P must be done no more than 30 days before or within 24 hours after admission and always before surgery; an H&P done before admission needs an update note.
• The operative report is written or dictated immediately after surgery, with a brief operative note if the full report is not available before transfer to the next level of care.
• Pre-anesthesia evaluation within 48 hours before surgery; post-anesthesia evaluation no later than 48 hours after.
• A final progress note may replace a discharge summary for stays under 48 hours with minor problems, normal newborns and uncomplicated deliveries when policy allows.