A health information (HI) consultant does not need to be credentialed. There are positions available that are generally entry level that do not require credentials. However, the credentialed HI will be the one in-charge of the non-credentialed HI. Therefore the more credentials you have the more you can move up the ladder so to speak.
•Is a unit medical record recommended for use in a LTC? Why or why not?
A unit medical record is recommended or must be maintained for every resident in a long term care facility. With a unit record, the patient is assigned a medical record number on the first admission to the facility. This number should be used to incorporate both the previous admissions and the current admission, giving the most comprehensive picture of the resident’s medical history and therapy. The previous records should be readily accessible to staff for use in the assessment and care planning process. Without this problems could arise and the patient gets medication they may be allergic to or a diagnosis that is inadequate.
•What is the AHIMA recommended retention time frame for LTC records?
If State law requires a different retention period, the more stringent between federal and state must be followed. AHIMA states 10 years retention time frame.
•Is it necessary to keep a Master Patient Index (MPI) in a LTC? Support your answer.
Every long term care facility should maintain a master patient index (MPI) and admission and discharge register. The computer-based patient record system is supported by the organization-wide master patient index or other resident identification mediation service that ensures accurate and timely resident identification. The master patient index (MPI) is a valuable reference for basic demographic information and resident activity (i.e. admission and discharge dates) within one source. It is used to identify that a resident had