Long Term Care

MED-REC SYSTEMS specializes in providing quality health information consulting services to long term care facilities with a focus on both the health care centers and residential facilities. Highly qualified AHIMA credentialed health information consultants assist in the analysis and organization of the health information systems.

The health information consulting services include an ongoing analysis of the medical record department. Detailed reviews of a selected sampling of clinical records, paper-based, electronic, or hybrid (paper-based and electronic), from admission to discharge, are completed as requested at each visit using data collection worksheets for documentation requirements per Indiana State Department of Health, State Operations Manual (Federal Regulations), and Joint Commission standards. Practical solutions for documentation and departmental issues are offered using the most current industry standards. Emphasis is placed on adherence to facility and corporate policies and procedures related to the medical record department.

Medical Record Coordinator training is another service offered to facilities. This includes coverage of audit completion, department tracking systems, thinning procedure, retention and storage, ICD-9-CM coding, release of information, and more.

Educational opportunities including in-services and workshops are available to all staff members.

Shop Forms and Manuals Online

MED-REC SYSTEMS has a variety of forms available for purchase. The state regulations, federal regulations, and accreditation standards are used in the guidance of the development of the forms. The forms are reviewed and revised as needed per regulatory changes.

Click Here to Shop for Forms Online

Med-Rec Systems offers Indiana and National clinical record policy and procedure manuals for the medical record department.

Click Here to Shop for Manuals Online

 

Consulting Services:

  1. Analysis and Organization of Health Information Services
  2. Medical Record Coordinator Job Description Review
  3. Training of Medical Record Coordinator
  4. Retention/Storage/Filing/Destruction of Records Review
  5. Pre-Survey Audits
  6. State and Federal Regulatory Updates
  7. Joint Commission Compliance
  8. Nursing and Interdisciplinary Staff Training on Legal Aspects of Documentation
  9. Confidentiality and HIPAA Privacy Act Training
  10. Quality Assurance Activities , Including QM/QI Review
  11. ICD-9-CM Training
  12. Development and Revision of Facility Forms
  13. Analysis and Assistance with Transition to Electronic Medical Records
  14. RAC Readiness Reviews

In-Service Topics:

  1. State and Federal Regulations for Health Information Documentation
  2. Completion of MDS 2.0 and RAP Summary Forms (The RAI)
  3. Transition to MDS 3.0
  4. Improving Supporting Documentation for Reimbursement
  5. Charting Techniques and Guidelines
  6. Interdisciplinary Care Plans: Requirements, Format, Content and Charting Progress
  7. Legal Aspects for Charting: Creating a Record that Defends Staff
  8. Confidentiality and HIPAA Privacy Act
  9. Admission/Discharge Documentation Requirements
  10. Most Frequent Health Information Documentation Survey Findings and Suggested Solutions
  11. Content of Nurses’ Notes: How to Improve Them
  12. ICD-9-CM Coding for Long Term Care
  13. Any Other Related Topic

Temporary Medical Record Support:

We can provide temporary support staff to assist with periodic health information processing needs. We offer quality service and flexibility to address your unique situation. Services include, but are not limited to:

  1. Record Completion
  2. Filing
  3. Interim Staffing
  4. ICD-9-CM