As HIM professionals, we learn the importance of documentation very early in our education and careers. And we know two things for sure:
- Every record represents a real person
- If it wasn’t documented, it didn’t happen
That’s why during any disaster, and today as we face COVID-19, it is HIM professionals who can rise to the occasion and provide a voice of reason and critical support to ensure that documentation of the crisis-related events is complete, concise, and accurate. Whether your HIM team is working on site, remotely, or a combination, and whether HIM services are considered essential or not, here are 12 things all HIM professionals should keep in mind when managing clinical information that must be accurate and complete in order to be effectively used for care, diagnosis, treatment, and payment.
| 1. | Patient Privacy | Review, download, and share the bulletin from the U.S. Department of HHS regarding HIPAA Privacy in Emergency Situations |
| 2. | Duplicate Accounts | Collection of demographic and key information should continue to the extent possible, with a reconciliation process in place to alleviate duplicate accounts |
| 3. | Medical Record Numbers | Each patient should continue to receive a unique medical record number and you should complete a daily Master Patient Index (MPI) review |
| 4. | Forms | Have a plan for any new forms or documentation that may be needed during the time of the disaster to ensure that each document is maintained according to organization, state, federal, and regulatory guidelines |
| 5. | Emergency Documentation Packets | Ensure that Organization Emergency Documentation Kits are reviewed, updated, and ready for quick access and storage and that a numbering convention exists for the kits to ensure reconciliation of usage |
| 6. | Consent Forms | Now is not the time to change forms so ensure that consent forms address virtual visits/telehealth/telemedicine, keeping in mind that a separate form may be needed to streamline the process |
| 7. | Virtual / Telehealth / Telemedicine Visits | Organizational policy regarding patient visits applies even though the patient is not physically within the provider’s office/facility; follow all policies — an account number and documentation are still needed |
| 8. | Patient Technology Support | Alleviate the impact on your IT team by utilizing some HIM staff to help patients access telehealth technology and to answer general questions |
| 9. | Coding, Billing, and Denials | Consider holding COVID-19 cases until test results are confirmed (like pathology report process) to ensure proper coding and minimize rework and potential denials |
| 10. | Patient Registries | Collaborate and offer support to collect information for registries that will be greatly needed as we move beyond COVID-19 |
| 11. | Downtime Processes | Continue to utilize as much organizational technology as possible during the disaster, but ensure that team members are aware of downtime processes should the technology not be available |
| 12. | Support and Resources | Utilize trusted resources to obtain information and answers to questions. Ciox’s COVID-19 Resources page has a wealth of information and is being updated frequently |
Finally, stress the importance of documentation, documentation, documentation. During times of disaster, caregivers are focused on one thing — patient care — and documentation is one of the last things on their minds. Identify unique, creative ways that you and your team can partner with caregivers, patient scheduling, registration, case management, patient financial services, and IT. Support, delivered with a warm smile and kind words, will go a long way in these challenging times. Take of yourself and each other and remember, we will get through this together!
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