Post Discharge HIM Routines

Nancy Weatherhead

Chapter 6: The Basics of the Inpatient Care Record

Post Discharge HIM Routines

Post-discharge processing is the steps that occur with a patient’s record upon discharge. In fully electronic environments, the record is already stored in the clinical information system, and post-discharge processing consists of ensuring that the record is accurate and complete before being archived. With a hybrid record, this also involves a series of procedures aimed at storage, or retention, of an accurate and complete physical record (Davis, 2019).

The post-discharge processing routine is managed and performed by the HIM department, with a wide variety of individuals involved, depending upon organizational size. While some of these functions, such as coding, are performed by certified health information management professionals (CHIMs), other tasks in this process may be completed by HIM clerks (often graduates of medical office administration diploma programs).

Identification of Records

Post-discharge processing starts with identifying patients who have actually been discharged. The HIM clerk can determine this by checking the discharge register, a list generated from the master patient index (MPI) that includes all patients discharged by date.

Shelves filled with neatly aligned manila file folders, labelled at the top edge with tabs of various colours, predominantly green, with some showing numbers and letters; the orderly arrangement suggests an efficient filing system, possibly in a records room. — When a patient is discharged, the p-Chart moves from the unit to the HIM department for assembly and further processing.

In a hybrid patient record environment, the physical chart (p-Chart) moves from the point of care, or patient care unit, to the HIM department after discharge. The HUC on the patient care unit typically dissembles the p-Chart on the day of discharge, and the record remains on the patient unit until the following morning to provide time for physicians and other clinicians time to complete their documentation (Davis, 2019). It is common for the HUC to leave dissembled discharge p-Charts in a designated pile/bin for pickup and for an authorized person, such as a HIM clerk or volunteer, to retrieve and deliver the charts to the HIM department at designated periods. In a hybrid or fully electronic environment, the electronic record (e-Chart) may be accessed by HIM staff without any physical transfers.

In hybrid environments, post-discharge processing cannot begin until the p-Chart actually arrives in the HIM. The HIM clerk must first check that there is a physical discharge chart for each entry on the discharge register and follow up with the patient care unit if there are any discrepancies. It is not uncommon for a patient to be discharged, yet no p-Chart sent to HIM. The most common reason for this is that the HUC forgets to disassemble or it was left in the charting area after a health care provider documented on it. However, in odd cases, it has been sent to another facility upon transfer, taken home by a patient, or even mistakenly put in the shredder! Early identification is essential to finding missing records, so HIM staff should contact care areas immediately to ascertain the patient’s status and whereabouts of the chart.

Assemble and Bind

Assembly is the process of reorganizing a paper record after discharge and preparing it for further processing—this is done manually for paper records by HIM staff members called assemblers (Davis, 2019). The amount of preparation required can vary, depending upon differences between the organization of the chart on the patient care unit and the HIM unit’s post discharge process and the care the HUC on the unit takes with the chart. Once the paper record is correctly organized, the pages are bound within a permanent manilla folder.

Though not as detailed, assembly may still occur within the e-Chart when there are paper records which have not yet been attached, such as advanced directives or consent forms, or printed reports which contain additional hand-written documentation. The assembler must then scan these to the e-Chart so that they are retained as part of the hospital record.

Quantitative Analysis (Analyzing for Deficiencies)

Next, the records undergo quantitative analysis, which is the formal process of reviewing a health record to ensure completeness and accuracy. HIM staff review the chart, often with the assistance of a checklist, to ensure that all required data is present, correctly completed, correctly labelled/identified, and includes the required signatures.

When a deficiency is found in a chart, the chart is flagged as incomplete, and the health care provider(s) with outstanding deficiencies are notified electronically. HIM departments typically provide a limited window for providers to address outstanding deficiencies, such as three to seven days. Providers who do not address deficiencies within this period may receive additional notifications with a series of escalating consequences, such as suspension of hospital privileges. Some quantitative analysis can be performed on e-Charts automatically by the clinical information system throughout the patient’s active stay done in real-time. This process is termed concurrent analysis. Quantitative analysis for p-Charts typically only occurs after discharge-which is termed retrospective analysis.

Coding and Abstracting

Coding is the process of analyzing clinical information within a health record, such as diagnosis and procedures and converting this into a universal medical alpha-numeric code for use in a database. Medical coding is performed all over the world, with most countries using the International Classification of Diseases (ICD) from the World Health Organization (WHO) (AAPC, 2024). The ICD is modified by each member country to serve its needs; Canada uses the International Statistical Classiﬁcation of Diseases and Related Health Problems, 10th Revision, Canada (ICD-10-CA), which was enhanced by the Canadian Institute for Health Information (2022) to specifically meet Canadian data.

CHIMs now use a computer app to both assist in the coding process and import certain data to other databases for a variety of purposes. CHIMs may perform the coding process remotely for e-Charts. In the case of hybrid records, the CHIM must review both the e-Chart and the p-Chart in the coding process. If the p-Chart has already been scanned into the clinical information system, this coding process may also be done remotely.

The term abstracting refers to the process of reviewing patient files, extracting key data and information, and entering it into another database or document for secondary use (Robert Half, 2019). An abstract summarizes a patient’s care to avoid reviewing the entire medical record. To create an abstract, the CHIM or HIM clerk checks the health record to confirm key details like MRN, account number, discharge status, and admission diagnosis. In electronic systems, this data is mostly pre-filled and just needs verification. In a hybrid record, the CHIM or HIM clerk ensures all important details are correctly entered after discharge.

Retain Chart

It is common to keep track of paper records during post-discharge processing by batching the records together by date of discharge. In this method, all records of discharges from June 3, for example, are gathered and kept together as they are moved as a group through assembly, analysis, and coding processes. Once finished these processes, they are divided by completion status. Completed records are taken to the scanning area or permanent file area for storage; incomplete charts are taken to the incomplete chart area. This same process is used to track paper documents that must be scanned (Davis, 2019).

The batch form can be beneficial if a p-Chart must be extracted from the processing cycle for reasons such as:

readmission,
release of information,
legal/insurance purposes, or
research purposes.

Complete fully electronic records require no further interventions at this point. Completed hybrid physical records which are not scanned must now be manually filed in the HIM department. The most common filing methods are outlined in the next two sections.