Please use the information that I have attached to answer the following question that's at the end of the chapter- (125 minimum word count and cite through out when using the attached reference)

Administrative and information systems support the management and clinical functions in the facility. In a hospital, these support functions are generally segregated into several departments. In nursing facilities, however, the functions are generally consolidated in one department, called the business office, except for medical records, which are typically under the supervision of the director of nursing. Information systems link various administrative and clinical functions. In the future, integrated networks will span across various health care organizations.

 

The Business Office

 

The business office generally combines reception, secretarial, clerical, and bookkeeping functions. Visitors, patients, family members, and associates have frequent contact with the business office. Most facilities have a front desk staffed by a receptionist and an adjoining office occupied by bookkeeping and other clerical staff. The receptionist also performs some secretarial and clerical duties.

 

The number of bookkeepers needed by the facility depends on two factors: the size of the facility and the business and accounting functions performed at the facility. Multifacility chain operations centralize most accounting and finance functions at their corporate offices, but the corporate office relies on the facility’s business office for vital inputs needed to prepare financial and management reports. Stand-alone facilities generally contract with an accounting firm to carry out most accounting and finance functions, but the bookkeeping staff at the facility performs basic routine functions and prepares inputs for accountants.

 

The business office is supervised by a business office manager, who is a department head reporting to the administrator. This individual also handles the facility’s bookkeeping. Even though the business office is open 5 days a week during regular business hours, facilities with 100 to 120 beds or more should have a receptionist for evenings and weekends. In smaller operations, telephone answering duties are taken over by a designated nursing station when the business office is closed.

 

Regulations do not mandate specific qualifications for the employees who staff the business office. Bookkeepers must be skilled in basic accounting functions. However, bookkeepers also have regular interactions with patients and families, so they must also have good communication skills. The bookkeepers also generally relieve the receptionist for lunch and break time, sickness, and vacations. Cross-training may also enable a facility to use other personnel, such as the medical records clerk, to cover the reception desk for brief durations.

 

The Front Desk

 

To most first-time visitors, the front desk provides a window into the facility. With their first contact, many people form lasting opinions about the rest of the operation and its services. A smile, a warm greeting, an offer of assistance, and an eagerness to meet people’s needs create a positive impression. Hence, the front desk should be staffed with personnel who can display a pleasant demeanor and also have the mental capacity to carry out clerical and secretarial duties in an atmosphere in which frequent interruptions and distractions are common.

 

Reception Duties

 

Front desk protocols should demand that every visitor to the facility is made to feel welcome. The receptionist must interrupt whatever he or she is doing and attend to the visitor. Once greeted, the visitors should be asked how they could be assisted. Knowledge of the facility, the location of resident rooms, the key functions of the different departments, the names of residents, and knowledge of some of the residents’ routines and habits can all play an essential role in directing visitors appropriately. The receptionist’s length of employment and experience with the facility can pay rich dividends here. An updated roster of residents, along with their room numbers, should be maintained at the front desk.

 

Effectively managed facilities maintain a notification system for the receptionist to know when certain key personnel are out of the facility or in meetings. A small board with the names of all key personnel can be easily updated to avoid embarrassing moments when a visitor may be kept waiting for someone who is eventually found to be unavailable. Having this type of a system also enables the receptionist to know who is available to attend to a walk-in or telephone inquiry from a prospective client at any given time.

 

The telephone must be answered within the first three to four rings. When more calls than one come in at the same time, keeping the caller on hold for several minutes after saying “Can you hold, please?” or “one moment, please,” is inappropriate. The bookkeeper(s), and other personnel if necessary, should assist the receptionist when the front desk gets busy. Once the call is picked up, the recommended protocol is an appropriate greeting followed by the name of the facility, followed by “how may I help you.” The call should then be directed promptly to the appropriate individual.

 

Secretarial and Clerical Duties

 

Depending on the facility’s size, the receptionist may be assigned additional duties, such as clerical work, minor bookkeeping tasks, filing, faxing, handling mail, and photocopying. At the administrator’s discretion, the receptionist may be responsible for handling the patient trust fund, or this task may be assigned to the bookkeeper. Size of the facility is a key factor that determines the extent to which the receptionist can handle clerical functions.

 

Accounting and Bookkeeping Functions

 

The main accounting and bookkeeping functions include payroll, accounts payable, the petty cash fund, billing for patient services, accounts receivable, the patient trust fund, and bank deposits. Trained bookkeepers may also be able to perform more advanced accounting functions, such as posting to the general ledger, doing payroll accounting and processing payroll checks for employees, processing payable checks for vendors, and completing quarterly tax forms. In this case, preparation of financial statements (income statement, balance sheet, cash flow statement, and certain managerial reports) and annual financial auditing will be contracted to an independent accounting firm. For nursing homes affiliated with a hospital or multifacility corporation, these functions are generally centralized at the corporate office, and the costs are passed on to the facility in the form of management fees. Nevertheless, for chain-affiliated facilities, centralized accounting functions are more cost effective than outsourcing them to an accounting firm.

 

Payroll and Compensation

 

Payroll accounting comprises three main activities: determining gross wages, deducting payroll withholdings, and calculating payroll-based contributions made by the employer on behalf of the employee. The actual pay employees receive is gross wages minus the withholdings. Employer contributions are regarded as benefits.

 

Employees are paid on the basis of their rates of pay and the hours they work. The administrator should authorize the initial rate of pay when an employee is first put on the payroll. For later changes in the established rate of pay, controls must be instituted for proper authorizations that would prevent any irregularities. The number of hours worked must be calculated strictly in accordance with established payroll policy.

 

This section is intended to provide a general overview of the main requirements of the Fair Labor Standards Act (FLSA) that governs payroll practices in businesses. The Wage and Hour Division of the U.S. Department of Labor is responsible for administering and enforcing federal labor laws.

 

Exempt and Nonexempt Employees

 

Under FLSA, all employees must be classified as either exempt or nonexempt. Nonexempt employees are paid an hourly rate, which must at least equal the minimum wage established under law. Nonexempt employees are also entitled to overtime pay (discussed later). Most employees in a nursing facility are nonexempt. These employees are issued time cards for each pay period and are required to punch a time clock that records the times when an employee came in to work (clocked in) and when the employee left work (clocked out).

 

Exempt employees are generally salaried and are exempt from the overtime provisions of the law. However, the mere fact that someone is salaried or holds a certain job title does not necessarily make that person exempt. Two main criteria that determine exempt status are the employee’s compensation and specific job duties. Both criteria must be met.

 

Criterion 1: Compensation

 

To qualify for exemption, employees must be paid no less than $455 per week on a salary basis. As a general rule, the full salary must be paid regardless of the number of days or hours worked during a given week. Exempt employees do not need to be paid for any workweek in which they perform no work.

 

Criterion 2: Job Duties

 

The emphasis is on the primary duties that constitute the nature of an exempt employee’s job even though a person may perform some nonexempt duties. FLSA regulations define three main “white-collar” categories. These categories, however, cannot be used arbitrarily with the intent of classifying certain employees as exempt:

 

•  Executive: The duties are primarily managerial in nature; the person supervises and directs the work of two or more full-time employees; and the person makes substantive recommendations on personnel decisions such as hiring, firing, or advancement of other employees. Under these guidelines, the facility’s administrator, assistant administrator, director of nursing, food service director, and perhaps a facilities manager who is in charge of all plant and environmental services would be exempt, provided they also meet the compensation test. Other department head positions in nursing homes are unlikely to be classified as exempt.

 

•  Administrative: The employee’s primary duty must be the performance of office or nonmanual work directly related to the management or general business operations of the employer or the employer’s customers. In addition, the employee’s primary duties must include the exercise of discretion and independent judgment with respect to matters of significance. It means that the employee has the authority to make an independent choice, free from immediate direction or supervision (Department of Labor, 2008). Except in very large facilities, it is unlikely that any nursing home employee would fall into this category.

 

•  Professional: The employee’s primary duty must be the performance of work requiring advanced knowledge, defined as work that is predominantly intellectual in character and that includes work requiring the consistent exercise of discretion and judgment. The advanced knowledge must be in a field of science or learning. The advanced knowledge must be customarily acquired by a prolonged course of specialized intellectual instruction. Only physicians and nurse practitioners are likely to qualify as exempt under this category.

 

FLSA has a special category of “highly compensated employees,” referring to those earning at least $100,000 annually of which at least $455 per week is paid on a salaried or fee basis. These employees are exempt as long as they customarily and regularly perform at least one of the duties of an exempt executive, administrative, or professional employee. There are other exemptions to FLSA that generally do not apply to health care facilities.

 

Minimum Wage

 

Effective July 24, 2009, the federal minimum wage was $7.25 per hour. A youth minimum wage of $4.25 per hour may be paid to those under the age of 20 but only during the first 90 consecutive calendar days after initial employment.

 

Future minimum wage increases are not automatic. Congress must pass a bill and the president must sign it into law before the minimum wage can go up. Many states also have minimum wage laws. In those states, the nonexempt employee must be paid the higher of the state or federal minimum wage.

 

Overtime Compensation

 

A workweek, which can begin on any day of the week, is seven consecutive 24-hour periods or 168 consecutive hours. Federal law mandates that nonexempt workers be paid overtime for any hours worked in excess of 40 hours in a work week. Although the 40-hour week is generally the standard for determining overtime, FLSA permits employers to enter into an agreement or understanding with a certain category of employees, such as nurses, whereby a work period of 14 consecutive days (instead of 7) may be established. Commonly known as the 8-80 rule, this alternative requires paying overtime for any hours in excess of 8 hours in any one day or for any hours in excess of 80 hours during the 14-day work period (Pozgar, 1992).

 

Overtime must be paid at the rate of time-and-a-half the regular rate of pay. Even when overtime is not authorized, if an employee has incurred it, it must be paid. As a general rule, nonexempt employees cannot be given compensatory time off in lieu of overtime.

 

The law does not require employers to pay more than an employee’s established rate of pay for working the evening shift, night shift, or weekends. However, to ensure adequate staffing, many facilities have established extra pay as an incentive for late shifts, weekends, and holidays.

 

Compensable and Noncompensable Time

 

Not all time spent at the facility is considered work time. Hence, it is important to distinguish between what is compensable and what is not. Determining where to begin and where to end the compensable time for a worker’s shift can be difficult. Hence, facility policy should clearly specify paid and unpaid time.

 

Meals and Breaks

 

Short rest breaks must be counted as work time. Some states require that employees be given a 10-minute break for every 4 hours of work. In other states, it is up to the employer to have a policy on short breaks; most employers do give short breaks of 10 or 15 minutes. When the length of rest breaks is specified by facility’s policy, any unauthorized extensions of break time need not be compensated. Meal periods (typically 30 minutes or longer) need not be compensated as work time. To avoid paying employees for meal time, the employees must be fully relieved of all duties and be free to leave their work stations, or the facility, during their meal breaks. It is particularly important to monitor meal breaks in facilities experiencing staff shortages and in facilities where well-meaning employees may have a tendency to “grab a quick bite” at the work station itself in order to minimize interruptions in patient care. If this is the case, the law would probably require that the employee be compensated for meal time. Similarly, meal breaks may be compensable if the employer requires that employees be available to respond to patient care needs when called. An example would be requiring employees not to leave the facility or wear pagers while on meal breaks. In Hoffman v. St. Joseph’s Hospital, the court held that respiratory therapists should be compensated for their 30-minute meal break because hospital policy required the employees to wear pagers during their meal breaks and they were subject to discipline if they failed to respond to pages.

 

De Minimis Time

 

Facility policy should specify the amount of time allowed as incidental time for preparatory and concluding activities. For instance, at the change of shift, workers may have to wash their hands, change into or out of uniform, etc. Also, many workers need to clock in or clock out at the same time, but generally some waiting time is involved, because they cannot all use the time clock simultaneously. This waiting time could be considered incidental time that is not compensable under law, as long as it is specified in the facility’s payroll policies. Courts have used what is referred to as de minimis doctrine—de minimis means “of minor importance.” Under this doctrine, 5 to 7 minutes, as a rule of thumb, spent at the time clock will not be compensable.

 

Integral and Indispensable Tasks

 

There is a fine line between de minimis and other tasks that courts have defined as “integral and indispensable” to an employee’s principal activities. For example, if the employer requires maintenance personnel to wash all equipment, such as a lawnmower, after each use, this is very likely an integral and indispensable part of the employee’s principal activity and must be compensated. Two tests need to be applied: (1) the task is necessary to the principal work performed, and (2) the task is done for the benefit of the employer.

 

Other Compensable Time

 

As a rule of thumb, time spent on anything that the employer requires must be compensated. For example, compensable work includes orientation, training, and inservice education that an employee is required to attend.

 

Limits to FLSA’s Jurisdiction

 

There are a number of employment practices that FLSA does not regulate. These compensation matters are governed mainly by the facility’s own policies and practices. For example, the FLSA law does not regulate:

 

  1.  Vacation, holiday, severance, or sick pay

 

  2.  Premium pay for weekend or holiday work

 

  4.  Pay raises or fringe benefits

 

  5.  A discharge notice, reason for discharge, or immediate payment of final wages to terminated employees

 

Payroll Withholdings

 

Employers are legally required to withhold taxes from their employees’ pay and to deposit the withheld amounts with the appropriate tax agencies (Jacksack, 1998). Taxes normally withheld from employee paychecks include federal, state, and local income taxes. Under the Federal Insurance Contributions Act (FICA), employers must also withhold half of the Social Security and Medicare taxes from the employees’ paychecks. Employers who fail to withhold and deposit taxes in a timely manner are subject to severe penalties and interest charges (Seawell, 1992).

 

The employer may also be required to withhold union dues for employees who belong to a trade union. Wage garnishment is another type of compulsory withholding. A wage garnishment is any legal or equitable procedure through which some portion of an employee’s earnings must be withheld by an employer to pay a debt incurred by the employee. Most garnishments are made by court order with which employers must comply. Other types of legal or equitable procedures include levies by the Internal Revenue Service (IRS) or a state tax-collection agency for unpaid taxes and federal agency administrative garnishments for nontax debts owed to the federal government.

 

There may be other withholdings that are voluntary, and these usually require the employee’s written consent. Voluntary withholdings include the employee’s portion of health insurance and life insurance premiums; employee’s contribution into a retirement plan; dental plan premiums; and premiums for other types of insurance, such as accident and disability.

 

Employer-Paid Tax Contributions

 

Employers must pay half of the FICA taxes on behalf of their employees. Also, under federal law, employers must pay unemployment taxes under the Federal Unemployment Tax Act (FUTA). In most states, the employer must also pay a state unemployment tax. These taxes are based on taxable wages paid to employees. In some states, employers are required to pay a disability insurance tax for workers’ compensation. Most states, however, allow the employer to cover workers’ compensation through private insurance purchased from a commercial insurance company (Seawell, 1992).

 

Other Bookkeeping Tasks

 

Most of the bookkeeping tasks are carried out according to general business practices. Management of the patient trust fund, particularly for Medicare and Medicaid patients, must comply with federal and state regulations.

 

Accounts Payable

 

Accounts payable is the accounting term for money owed to vendors from whom goods, supplies, and services have been purchased on credit. With the exception of minor and nonroutine purchases, most goods and services are purchased on a noncash basis. An invoice showing the amount due may accompany the goods at the time they are delivered to the facility, or it may be mailed separately. Service vendors also issue an invoice.

 

A common practice among most vendors is to extend credit for 30 days. Utility companies for telephone, gas, electricity, water, and sewer may allow less than 30 days for full payment of the amounts due. Payments are generally made by check and are recorded in the general ledger, which is maintained on a computer-based accounting system. As each invoice is paid, it is indelibly stamped or perforated “PAID” to prevent double payment (Seawell, 1992). All invoices must be authorized by the appropriate department heads before they are paid.

 

Petty Cash Fund

 

To pay for certain cash purchases and other small incidental expenses, a facility must maintain a petty cash fund. Petty cash is maintained in a locked box or drawer.

 

The facility should establish a policy on the imprest amount and on the maximum amount per disbursement that the business office can incur without requiring authorization from the administrator. The imprest amount is a fixed amount, such as $500, which is maintained by periodically replenishing the cash that has been disbursed.

 

Each disbursement from the petty cash fund requires completion of a petty cash voucher to which any supporting documentation, such as a sales receipt from a store, is attached. The voucher is signed by the person receiving the money. The cash and the amounts shown on the vouchers must always add up to the imprest amount. This system allows the administrator to periodically check the petty cash fund. When the amount of cash drops below a predetermined level, the vouchers are removed and totaled. Cash equaling this total is replenished, and the petty cash fund once again equals the imprest amount. Inconsequential shortages may occur because of errors, but substantial or frequent shortages could indicate mishandling of funds.

 

Billing, Accounts Receivable, and Collection

 

Just as the nursing facility receives products and services from outside vendors and does not pay cash for them right away, it similarly provides services to patients but does not get paid for those services immediately. The facility, however, has the legal right to receive money at a future date. The amounts that remain to be collected by the facility for services already rendered are called accounts receivable.

 

The facility must bill the respective payers such as Medicare, Medicaid, private insurance companies, or individual private parties responsible for paying. Bills are prepared and sent to the payers once a month. Medicaid and Medicare bills, called claims, are submitted electronically to the fiscal intermediaries contracted by Medicaid and Medicare to pay claims from providers.

 

The billing system should be set up so each patient is accurately classified according to pay type. It is particularly important to keep track of changes in pay status, when a patient’s payment status switches from one pay type to another, such as from Medicare to Medicaid, or from Medicare to private pay. The billing system must also separate the copayment and any other amounts that must be collected from the patient or from his or her representative party.

 

The basis for daily charges is the midnight census report, which is prepared each night by the charge nurse on duty and verified by the director of nursing. The midnight census report verifies the presence of each patient in the facility during the night. On a daily basis, the bookkeeper should match patients in the billing system against the midnight census report.

 

The daily charge, or the per-diem rate, covers room, board, nursing care, and other routine services. Depending on the payer, other services may or may not be covered by the per-diem rate. Any services or supplies not covered by the per-diem rate must be billed separately.

 

On a daily basis, the various patient charges as well as all payments received are posted to each patient’s ledger account. These ledger accounts are used to prepare a monthly accounts receivable aging report, which is a managerial report, not a financial statement. Also known as an aging schedule, this report provides a detailed account-by-account analysis of outstanding balances on unpaid patient accounts. It also shows account balances according to the number of days a given balance has been outstanding (Seawell, 1992). For instance, each account shows the receivable balance under columns for 0–30 days, which is considered “current,” 31–90 days past due, 91–120 days past due, and over 120 days past due. The older an unpaid account gets, the less likely it is to be collected. Facilities often jeopardize their own financial standing by neglegting to collect accounts receivable.

 

Third-party claims are often rejected because of billing errors. The only way such accounts can be collected is by rectifying the errors and resubmitting corrected claims. To collect past-due balances owed by private individuals, the facility must have collection policies and procedures.

 

The following guidelines can be used by facilities to formulate their own collection policies: accounts receivable are considered current during the first 30 days. However, even before an account balance gets to be 30 days old, a telephone call should be made to the party responsible for paying the private portion of the bill. The objective of this call is to remind the individual that a specified amount is due. The caller should also ask when payment might be expected and try to reach an agreement with the payer on a payment date that is no later than 1 week after the phone call. A week later, a second call should be made if payment has still not been received. The caller should now try to find out whether there is a reason why payment was not made and whether there is some problem with the bill and the amount due. Again, the caller should try to obtain some form of a promise to pay (Frew & Frew, 1982). A friendly tone must be maintained by the facility’s representative during these telephone conversations. The administrator should institute a system that enables the staff to conduct timely follow-ups and maintain documentation on each conversation. Detailed notes are helpful for any subsequent follow up. Generally, when an account is in arrears for 45 days or more, a letter should be mailed to the party responsible for paying the bill. The letter should contain a request for payment in a manner that is firm but does not present an ultimatum (Frew & Frew, 1982). Any subsequent letters should still be polite but should contain a stronger tone, including a warning that use of a collection agency may be necessary if the balance is not paid by a given date. By the 90th day of being past due, an account should be turned over to a collection agency.

 

Cash Receipts and Deposits

 

Control of cash receipts is a critical function. All cash and checks must be recorded on a cash receipt voucher that shows the exact amount received. Actual cash received must be kept separate from any other cash funds such as the petty cash fund or the patient trust fund. No cash disbursement should ever be made out of cash receipts (Seawell, 1992). Cash and checks must be deposited into the facility’s bank account daily. The bank deposit slip should be reconciled against the cash receipt vouchers, which are then used for posting credits to the respective patients’ ledger accounts. The ledger account for each patient shows the debits or amounts initially owed, credits or amounts paid, and the accounts receivable due.

 

Patient Trust Fund

 

Nursing home regulations allow residents to retain the right to manage their own financial affairs. However, many residents ask the facility to manage their personal funds. When asked to do so, the nursing home is obligated to establish a patient trust fund. The facility is not allowed to charge Medicare and Medicaid patients any fee for managing the trust fund.

 

Medicare and Medicaid certification regulations mandate that nursing homes deposit into an interest-bearing account all individual patient funds exceeding $50. Up to $50 per resident may be held in a noninterest-bearing account or petty cash fund held at the facility.

 

Patient funds are in a demand trust with the facility, which means that the funds are available to the patient upon request (Abramovice, 1988). In addition, the money can only be spent by the facility with specific permission from the patient or from someone authorized by the patient. Yet, an investigation by USA Today found that between 2010 and 2013, more than 100 nursing home employees had been prosecuted for stealing money from resident trust funds, in some cases, totaling tens of thousands of dollars (Eisler, 2013). To manage the patient trust fund, the facility should:

 

•  Open an interest-bearing account; this account must be separate from the facility’s own bank account.

 

•  Maintain a petty cash system that is separate from the facility’s own petty cash fund. Patients must have access to their funds during normal office hours.

 

•  Implement a cash receipt or cash ledger system to record each transaction. The records should include the patient’s name, account number, amount of cash withdrawn or deposited, and the purpose for which funds were withdrawn (such as cash, telephone bill, purchase of clothing, etc.). The signature of the patient or the patient’s authorized representative should be required for each transaction, unless there is an invoice bearing the patient’s name to support the disbursement of funds.

 

•  As a safeguard against misuse of funds, balances must be reconciled each month by someone other than the person responsible for maintaining the fund.

 

•  Regulations require the facility to provide the patient or the authorized person a statement at least once every quarter. The quarterly statement should include, at a minimum, the balance at the beginning of the period, current balance, amount of interest earned, total deposits and withdrawals, and detailed information on each transaction.

 

•  The full balance of funds belonging to a patient must be returned promptly after a patient has been discharged from the facility. After a patient’s death, a written statement must be sent to the administrator of the resident’s estate.

 

•  The facility must notify Medicare and Medicaid residents when the funds attain a level within $200 of the resource limit for Supplemental Security Income (SSI) or Medicaid. Such residents must be informed that if they go over the SSI or Medicaid resource limits, they may lose eligibility for the SSI and Medicaid programs.

 

•  The facility is required by law to purchase a surety bond or provide evidence of self-insurance, such as facility funds that are irrevocably set aside for repaying the residents in case of loss.

 

Medical Records

 

Staffing

 

Depending on the size of the facility, medical record services are staffed by a full- or part-time individual. Credentials of registered health information administrator (RHIA) or technician (RHIT), conferred by the American Health Information Management Association (AHIMA), is a necessary qualification for hospital medical records personnel. Certification is based on academic qualifications and an examination. Only large nursing homes may be able to employ someone credentialed as RHIA or RHIT. Most facilities designate a clerical person with some relevant experience or training to handle medical records and contract with a duly certified medical records consultant, who provides routine oversight.

 

Functions

 

The medical records clerk must ensure that medical records are completed within a reasonable time. When a resident is first admitted, a new chart for that resident is opened by the medical records clerk. In case of a readmission, the previously closed record is reactivated. Open records are maintained at the nursing station responsible for the care of the patient. The medical records clerk is responsible for ensuring that the records are maintained in an organized manner in accordance with current laws and accepted professional standards. Quality is ensured by auditing records according to an audit schedule. Upon discharge, the patient’s clinical record is closed and moved to the medical records office. Before the closed records are filed away, they are reviewed for completeness and compliance with regulations and the facility’s policies.

 

Standardized methods exist for systematizing, indexing, and filing medical records. The medical records clerk is responsible for the safekeeping, confidentiality, and retrieval of stored records. Paper medical records on patients who have been in the facility for a long time can become quite bulky. Such records can be thinned in accordance with the facility’s policies and regulatory provisions. However, clinical medical records in nursing homes are increasingly being computerized, although the progress has been slow.

 

Medical Record Content

 

A patient’s medical record contains all significant information on the care of the patient from admission to final discharge. Thus, it becomes a permanent and comprehensive historical record of the patient’s medical condition, the course of treatment and specific services delivered during the patient’s stay in the facility, and the clinical outcomes. Timeliness, objectivity, accuracy, and brevity without the sacrifice of essential facts are the hallmarks of effective medical recording (Bruce, 1988).

 

The medical record includes a patient’s identifying information as well as the patient’s clinical information. The patient’s identifying information includes name, address, gender, date of birth, Social Security number, Medicare and/or Medicaid claim number, marital status, name and contact information on next of kin, race and ethnicity, and religious preference. Clinical information includes records of medical and social history, physical examinations, principal diagnoses, results of the initial assessment and any subsequent reassessments, informed consent and advance directives, plan of care, treatments prescribed, diet plan, therapeutic procedures carried out, and medications administered. Also included in the clinical information are records of laboratory test results, clinical observations, response to treatment, any change in condition and action taken, any incidents or accidents, any treatment errors and action taken, any adverse reaction to medications, any use of restraints and psychotropic drugs, and discharge summary. All physicians’ orders must be signed and dated by the attending physician.

 

Typically, medical records are arranged in chronological sequence and divided into sections by the source of documentation. Thus, typical sections include those for physicians’ notes, clinical laboratory, social services, nurses’ notes, and dietary records. Another method uses an integrated format in which physicians and other health care professionals enter all progress notes in chronological order on one form, rather than in separate sections. This format promotes interdisciplinary collaboration because each discipline can easily see documentation furnished by others (Kiger, 2003).

 

State laws dictate the length of time for which medical records must be stored. The length of time for retaining medical records should also take into consideration the statute of limitations, a period prescribed by law within which a legal action can be taken, which varies from one state to another (Bruce, 1988).

 

Purpose of Medical Records

 

The primary purpose of medical records is to assist caregivers in coordinating services provided to a patient. Individual medical records provide all relevant information on each patient in one place to a diverse group of caregivers. These records help the interdisciplinary caregivers coordinate their efforts.

 

From the patient’s standpoint, the medical record ensures continuity of care because it provides vital information needed by all caregivers. Each caregiver can also see what staff members from the other disciplines may be doing to address patient needs.

 

Medical records provide documentary evidence of actual care rendered. Regulators and third-party payers rely on the medical records as a basis for determining compliance with requirements. The documentation also forms the basis for payment for services delivered and for evaluating whether the services provided were clinically necessary. Medical records provide vital information for improving quality and for research.

 

Medical records are summoned in malpractice cases. As part of a facility’s defense during litigation proceedings, timely, complete, and accurate medical records are essential to demonstrate that all reasonable and necessary care was provided. It is important for nursing home administrators to become familiar with the system of medical records used in their facilities. Administrators should review these records as part of their investigation when allegations of lapses in care are made by family members, regulators, or others. Common abbreviations used in patient documentation are listed in Appendix 13–1.

 

The facility retains ownership of the medical record, but the information contained in it belongs to the patient. Privacy of patient information contained in the medical records is a legal requirement under the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

 

Information Systems

 

Information systems are computer-based applications used for transforming raw data into information that can be used in a variety of ways to improve operational efficiencies and the quality of services. Data themselves do not constitute information. Discrete data become information only when the data have been accurately recorded, organized, processed, interpreted, and used. Large quantities of data can be processed by computer software programs to produce summaries and reports that can help employees do their jobs more effectively and to help managers make decisions for improving the operations. Most nursing homes use information systems for Minimum Data Set (MDS) reporting; to manage admissions, transfers, and discharges; and for budgeting and financial controls. On the other hand, adoption of electronic health records and use of advanced information systems for clinical functions in long-term care lag behind that in other health care organizations (Wang & Biedermann, 2012). The main barrier to the adoption of information technology is the high cost associated with both the hardware and software (Cherry et al., 2008). Nursing homes may be more inclined to adopt clinical information systems if it could be demonstrated that their use would improve quality and reduce costs. Unfortunately, research specific to nursing homes in this area is scarce (Spinelli-Moraski & Richards, 2013), although the use of information technology in hospitals has shown major improvements in quality of care. However, in a rapidly changing health care system, long-term care facilities will need to expand their capabilities to handle medication administration, physician orders, laboratory results, and daily care (MacTaggart & Thorpe, 2013).

 

On the administrative side, information system applications can be expanded into staff scheduling, menu planning and food ordering, inventory management, activity planning, and preventive maintenance scheduling. Information systems can also be used to manage the facility’s marketing program and to keep track of inquiries, follow up, and admissions generated from inquiries.

 

Meaningful information can facilitate instituting managerial controls, making timely decisions, making quality assessments, and delivering improved patient care. For example, summaries of accounts payable help management identify unauthorized payments to vendors. Other reports help management to study labor-hour use and overtime in order to control labor costs, to monitor aging of accounts receivables to identify and collect past due accounts, and to control costs using budget variances.

 

Integrated Networks

 

Integrated information system networks go a step beyond the functions described in the previous section. These systems are designed to integrate multiple functions and provide multiple users access to the same information. Several examples can be given to illustrate how integrated information systems can support more efficient management planning and decision making:

 

•  Staffing: Absenteeism and turnover patterns can be incorporated into staff scheduling to minimize understaffing. Staff turnover patterns can be projected to determine future hiring and training needs. Clinical information can be incorporated to determine the appropriate staffing levels and skill mix needed in accordance with the overall patient acuity levels indicated by the facility’s case mix.

 

•  Capital budgeting: Preventive maintenance and repair history can be used for forecasting future capital needs for equipment replacement. Such information can help the administrator decide at what point it makes better financial sense to replace equipment than to repair it.

 

•  Quality improvement: Data pertaining to a variety of clinical outcomes—such as infections, falls, and medication errors—can be analyzed to better understand their causes and to propose actions for minimizing negative outcomes. Standardized clinical practice guidelines can be integrated with assessment and care plans to improve care delivery. Clinical practice guidelines are protocols based on research and expert opinion for patient care delivery in specifically identified areas needing clinical intervention, such as falls reduction, pain management, prevention of pressure ulcers, and incontinence care. Use of these guidelines is an important step toward ensuring high-quality nursing home care.

 

•  Operational budgeting: Historical data on census patterns, associated revenues, and costs can be automatically retrieved to project future budget needs.

 

•  Marketing: Data on inquiries, follow-up, and admissions can be analyzed to determine the type of patients the facility is admitting in terms of pay types and acuity levels. The system can also help identify the major sources of referral and determine why certain patients may have selected other facilities.

 

In future, integrated networks across various health care providers will be necessary. For example, the Affordable Care Act places increased emphasis on care coordination and use of home- and community-based services, such as the Community First Choice. Coordination of long-term care services along the continuum of care—that would include home care, custodial care, skilled nursing care, and mental health services—would require integrated systems.

 

National Data

 

Comparison of a facility’s operations with state and national benchmarks will become increasingly common. The Online Survey Certification and Reporting (OSCAR) system is a national database of certification deficiencies and other information collected during facility surveys. One important use of this database is in providing benchmarks on survey deficiencies. For example, under Nursing Home Compare, the Centers for Medicare and Medicaid Services (CMS) makes available on its website detailed information on survey results and staffing for every certified nursing home in the United States.

 

Security Issues

 

Integrated information networks are fast becoming indispensable, but safeguarding of sensitive information presents challenges. Administrators must grapple with the critical question of who should have access to what information on the network. For instance, the facility’s financial information should not be accessible to everyone who uses a computer terminal in the facility. The system must also have adequate safeguards to prevent tampering with existing data. Some high-profile cases of break-ins by external hackers into computer systems of major U.S. corporations and the government further highlight the need for adequate security measures. Other security issues pertain to the physical security of the equipment. For instance, having backup records in case a system is destroyed in a disaster or is vandalized is essential.

 

System Development

 

Most nursing facilities must rely solely on outside vendors to meet the needs of their information systems. Numerous vendors specialize in hardware, software, and set-up of local area networks (LANs) within the facility. A LAN links a group of computers to a central server so the LAN users can access the same information. Because a turnkey system can be quite expensive, a decision to upgrade existing systems should not be undertaken without careful study and planning. The administrator must first define the objectives of the system in terms of what the system should be able to accomplish. These objectives must specify the level of integration a proposed information system must achieve. Current capabilities should then be evaluated in conjunction with these desired objectives. In some cases, certain upgrades may enable the facility to reach its objectives. In other instances, replacing the existing system may be the best alternative.

 

Several reputable vendors should be invited to evaluate the current systems and desired objectives and to submit detailed written proposals along with costs. The facility may not be able to purchase a fully integrated system immediately. In that situation, feasibility of future upgrades should be discussed. In any case, making a firm commitment is not advisable without a test run to ensure that the system would indeed accomplish what the facility desires. Finding out what kind of ongoing support and training the vendor provides and how often the vendor upgrades products to meet changing needs and improve informational efficiency are also critical. Another important consideration is the system’s compatibility with Medicare and Medicaid billing and with clinical data requirements. For instance, the system should enable electronic billings as well as electronic transmission of patient assessment information. Finally, the system must comply with all applicable laws and regulations.

 

Question- Why is it important that the petty cash and patient trust fund be reconciled each month and that the reconciliation be done by someone other than the person responsible for maintaining the funds?

 

 

Attachments:

• 1507039105-Administrative and information systems support the management and clinical functions in the facility.docx