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 DOCUMENTATION for
HEALTH RECORDS
Second Edition

Cheryl Gregg Fahrenholz, RHIA, CCS-P

Lead Author

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Lack of Healthcare Consumer Awareness. . . . . . . . . . . . . . . . . . . . 140

Cybersecurity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Components of the EHR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Specialty-Based EHRs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Federal Policies Driving EHR Implementation. . . . . . . . . . . . . . . . . . . . 143
National Infrastructure for the EHR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Providers and the Infrastructure for EHRs. . . . . . . . . . . . . . . . . . . . . . . 144
User Access. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Documentation Standards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Clinical Decision Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Data Dictionary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Designing an EHR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Data and Information in an EHR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Nonclinical Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Demographic Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Financial Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Preliminary Clinical Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Consents and Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . 149
Documenting in the EHR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Devices Used to Document in the EHR. . . . . . . . . . . . . . . . . . . . . . . . . 150
Regulating Health Record Content. . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Clinical Documents in the EHR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Medical History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Report of Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Physician Orders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Outpatient Services Provided in Acute-Care Facilities. . . . . . . . . . . 154
Specialty-Care Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Discharge Summaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Autopsy Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Uses for Abstracted Electronic Data . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
The Hybrid Health Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Health Record Storage Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
HIM Functions in an EHR Environment. . . . . . . . . . . . . . . . . . . . . . . . . 159
Authentication of EHR Entries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

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Guidelines to Prevent Fraud and Ensure EHR Documentation

Integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Medical Identity Theft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Authorship Integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Auditing Integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Documentation Integrity: Automated Insertion of Clinical Data. . . 160
Corrections in Electronic and Clinical Documentation . . . . . . . . . . . . . 161
EHRs in Health Information Exchanges. . . . . . . . . . . . . . . . . . . . . . . . . 161
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Chapter 6 Clinical Documentation Improvement. . . . . . . . . . . . . . . . . . . . . 167
The Importance of Clinical Documentation . . . . . . . . . . . . . . . . . . . . . 168
Evidence-Based Documentation: The Theory of High-Quality
Clinical Documentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Seven Criteria for High-Quality Clinical Documentation. . . . . . . . . 169
Operational Considerations of the CDI Process. . . . . . . . . . . . . . . . . . . 174
The CDI Professional . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Queries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Concurrent Query. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Retrospective Query . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Query Format. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
CDI and the EHR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Translating Clinical Documentation into Coded Data. . . . . . . . . . . . . . 185
How a Coding Professional Views an Inpatient Health Record . . . . 185
The Relationship between Clinical Documentation and Coding. . . 188
Clinical Documentation Analysis and Assessment. . . . . . . . . . . . . . . . . 191
Data Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Chapter 7 Information Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Quality and Safety of Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
The IG Principles and Examples for Each in Healthcare. . . . . . . . . . . . . 207
IG and Patient Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Clinical Documentation Improvement. . . . . . . . . . . . . . . . . . . . . . 208
Meaningful Use Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Coding and Quality Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Learning Health System and Quality Improvement . . . . . . . . . . . . 210

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The Role of HIM in Information Governance . . . . . . . . . . . . . . . . . . . . 212

Adaptive Leadership and IG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Examples of IG Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Chapter 8 Data Analytics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Tools Used in Data Analytics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Microsoft Excel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Tableau. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Qlik View. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
R Studio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Public Data Web Sources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
National Initiatives on Big Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Concepts of Database Management . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Data Analytics and the Electronic Health Record . . . . . . . . . . . . . . . . . 229
Tools and Best Practices When Conducting Research in an
EHR Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Clinical Care, Data Analytics, and the EHR . . . . . . . . . . . . . . . . . . . . . . 230
Quality and Population Health and the EHR . . . . . . . . . . . . . . . . . . . . 231
Data Governance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236

Part III Organization and Management of the Health Record . . . . . . . 239

Chapter 9 Federal and State Requirements and Accreditation
Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Federal and State Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Federal Healthcare Statutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
HIPAA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
HITECH Act. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
Federal Patient Safety Legislation. . . . . . . . . . . . . . . . . . . . . . . . . . 248
CMS Regulations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
Medicare Conditions of Participation. . . . . . . . . . . . . . . . . . . . . . . 250
Medicare Compliance Surveys. . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Telehealth Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
CMS Quality Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Patient Satisfaction as a Quality Measure. . . . . . . . . . . . . . . . . . . . 254
Quality Improvement Organizations . . . . . . . . . . . . . . . . . . . . . . . 256

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Healthcare Corporate Compliance. . . . . . . . . . . . . . . . . . . . . . . . . . . . 256

Office of Inspector General and OIG Work Plan. . . . . . . . . . . . . . . 257
Recovery Audit Contractors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Federal and State Protection of Sensitive Health Information . . . . . . . . 259
Substance Abuse Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Behavioral Health Records. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
HIV/AIDS Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Genetic Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
State Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Licensure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Medicaid Eligibility and Administration. . . . . . . . . . . . . . . . . . . . . 261
Medicaid Compliance Programs . . . . . . . . . . . . . . . . . . . . . . . . . . 262
Accreditation Requirements for Acute-Care Hospitals. . . . . . . . . . . . . . 262
The Joint Commission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
Healthcare Facilities Accreditation Program. . . . . . . . . . . . . . . . . . 266
DNV GL Healthcare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Center for Improvement in Healthcare Quality . . . . . . . . . . . . . . . 267
Internal Hospital Policies and Procedures. . . . . . . . . . . . . . . . . . . . . . . 268
HIM Policies and Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Medical Staff Bylaws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Medical Records Committee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
Chapter 10 Ambulatory Care Documentation, Accreditation, Liability,
and Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Ambulatory Surgical Centers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
Community Health Centers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Private Practice Providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
Diagnostic Imaging Centers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
Missing Clinical Information in Outpatient Services . . . . . . . . . . . . . . . 279
Ambulatory EHR versus Hospital EHR. . . . . . . . . . . . . . . . . . . . . . . . . . 280
MU Criteria for Eligible Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . 283
MU for Eligible Providers by Stages. . . . . . . . . . . . . . . . . . . . . . . . 283
Credentialing and Licensure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
State and Federal Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
Governmental Regulations of Ambulatory Care. . . . . . . . . . . . . . . 286

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State Governments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288

Ambulatory Care Accreditation Standards . . . . . . . . . . . . . . . . . . . . . . 289
Types of Ambulatory Accreditation Organizations . . . . . . . . . . . . . . . . 290
The Joint Commission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Accreditation Association for Health Care . . . . . . . . . . . . . . . . . . . 291
The Accreditation Association for Ambulatory Health Care . . . . . . 291
Association for American Accreditation of Ambulatory Surgery
Facilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
American College of Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
Commission on Accreditation of Rehabilitation Facilities . . . . . . . . 292
Community Health Accreditation Partner . . . . . . . . . . . . . . . . . . . 292
The College of American Pathologists . . . . . . . . . . . . . . . . . . . . . . 292
Commission on Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
National Committee for Quality Assurance . . . . . . . . . . . . . . . . . . 292
Role of the Patient’s Primary Care Physician and the Maintenance of
Health Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Document Management and Imaging System. . . . . . . . . . . . . . . . . . . 294
Type of Document Imaging Scanners . . . . . . . . . . . . . . . . . . . . . . 294
Documenting Imaging Best Practices . . . . . . . . . . . . . . . . . . . . . . 295
Risk Management and Liability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Chapter 11 Long-Term Care Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
Long-Term Acute-Care Hospital Settings . . . . . . . . . . . . . . . . . . . . . . . 304
Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Federal Regulations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
State Regulations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
Accreditation Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
Components of the LTCH Prospective Payment System. . . . . . . . . 307
LTCH Health Record Content. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
History, Physical, and Referral Information. . . . . . . . . . . . . . . . . . . 308
Principal Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
Admission Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Physician Orders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Progress Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Problem Lists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310

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Consultation Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310

Reevaluations and Assessments. . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Advance Directives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Laboratory Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Specialty Reports. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Flow Sheets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Graphical Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Care Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Procedure Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Miscellaneous Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Medication Administration Records. . . . . . . . . . . . . . . . . . . . . . . . 313
Discharge Documentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
LTCH Policies and Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
LTCH PPS Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
Chapter 12 Facility-Based Long-Term Care . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Skilled Nursing Facility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
SNF Health Record Content. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
Resident Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
Resident Assessment Protocols. . . . . . . . . . . . . . . . . . . . . . . . . . . 328
Other Documentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
SNF Accreditation Standards and Regulations . . . . . . . . . . . . . . . . . . . 334
Medical Necessity and Medicare Documentation . . . . . . . . . . . . . 335
Physician Certification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Standards Governing Assessments. . . . . . . . . . . . . . . . . . . . . . . . . 335
Medicare Quality Indicators for SNFs. . . . . . . . . . . . . . . . . . . . . . . 336
Risk Management and Liability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
Real-World Case Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
Chapter 13 Home Care and Hospice Documentation, Liability,
and Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Home Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
What Is Medicare-Certified Home Health? . . . . . . . . . . . . . . . . . . . . . . 343
Certified Hospice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344

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Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
Home Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
Home Health Payment Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
Standard Core Assessment Tool—OASIS . . . . . . . . . . . . . . . . . . . . 345
Hospice Conditions of Participation. . . . . . . . . . . . . . . . . . . . . . . . 345
Hospice Core Assessment Tool—HIS . . . . . . . . . . . . . . . . . . . . . . . 346
Increasingly Complex Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . 346
Government Influences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
Office of Inspector General Oversight . . . . . . . . . . . . . . . . . . . . . . 347
Comprehensive Error Rate Testing (CERT). . . . . . . . . . . . . . . . . . . 348
The Medicare Home Care Benefit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348
Documentation of Eligibility of the Provider . . . . . . . . . . . . . . . . . 349
Home Health under the Care of a Physician. . . . . . . . . . . . . . . . . . 349
Home Confinement (Homebound Status). . . . . . . . . . . . . . . . . . . 350
Skilled Services Requirement for Benefit Eligibility . . . . . . . . . . . . . 351
First Visit Criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
Intermittent or Part-Time Nursing. . . . . . . . . . . . . . . . . . . . . . . . . 352
Home Health Prospective Payment System . . . . . . . . . . . . . . . . . . 352
The Medicare Hospice Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356
Provision of Care under the Medicare Hospice Benefit and
Documentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
Payment System for Hospice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
Home Health and Hospice Record Content . . . . . . . . . . . . . . . . . . . . . 358
Intake/Referral. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
Home Care and Hospice Assessment Information. . . . . . . . . . . . . . . . . 361
Home Care and OASIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
Hospice and Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
Home Health Plans of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
Hospice Plans of Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
Hospice Clinical and Progress Notes . . . . . . . . . . . . . . . . . . . . . . . 366
Home Health Clinical Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366
Dietary and Nutritional Information . . . . . . . . . . . . . . . . . . . . . . . 367
Bereavement Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Progress Notes and the Discharge Transfer Record . . . . . . . . . . . . 367
Medicare Home Care Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368

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Quantitative Record Review Guidelines . . . . . . . . . . . . . . . . . . . . . . . . 370

Home Health Medical Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Medicare Hospice Surveys. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
Home Health QAPI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
Medical Review of Hospices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
Medicare Hospice Quality Assessment Performance
Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
Physician’s Documentation Review . . . . . . . . . . . . . . . . . . . . . . . . 375
Home Care and Hospice Legal Issues. . . . . . . . . . . . . . . . . . . . . . . . . . 376
Patient’s Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
Patient Self-Determination Act of 1990. . . . . . . . . . . . . . . . . . . . . 377
Do-Not-Resuscitate Orders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
Home Health Quality Initiative. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380
Patient Outcome Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
Accreditation Quality Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . 382
CHAP Performance Improvement Standards. . . . . . . . . . . . . . . . . 383
The Joint Commission Performance Improvement Standards. . . . . 383
General Requirements of Documentation. . . . . . . . . . . . . . . . . . . . . . . 383
Communication and Timeliness of Documentation. . . . . . . . . . . . 383
Consistent and Complete Documentation. . . . . . . . . . . . . . . . . . . 384
Development of Documentation Policies and Procedures . . . . . . . 384
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386
Chapter 14 Exploring Other Healthcare Settings. . . . . . . . . . . . . . . . . . . . . . 391
Regulations Common to All Healthcare Providers. . . . . . . . . . . . . . . . . 392
Outpatient Private Practitioners or Solo Practitioners. . . . . . . . . . . 393
Outpatient Ambulatory Integrated Clinical Settings. . . . . . . . . . . . 409
Government Healthcare Settings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419
Veterans Health Administration. . . . . . . . . . . . . . . . . . . . . . . . . . . 419
Other Military Healthcare Systems. . . . . . . . . . . . . . . . . . . . . . . . . 420
Correctional Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420
Indian Health Service. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Other Healthcare Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
Blood Banks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
Coordinated School Health Programs . . . . . . . . . . . . . . . . . . . . . . 423
University-Based Student Health Services. . . . . . . . . . . . . . . . . . . . 424

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Veterinary Practices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424

Critical Access Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
A Note on Health Plans and Insurers . . . . . . . . . . . . . . . . . . . . . . . . . . 428
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469

Online Appendices

Available at http://www.ahimapress.org/fahrenholz5542/.

Appendix 3A Sample Consent Form

Appendix 3B EHRs Serving as the Business and Legal Records of Healthcare
Organizations
Appendix 3C Individual Access to Medical Records: 50 State Comparison
Appendix 4A NCVHS Measurement Framework for Community Health and
Well-Being, Vol. 4
Appendix 5A Paper-Based Health Record Forms
Appendix 11A Long Term Care Hospital Prospective Payment System
Appendix 14A Medical Record Retention Required of Health Care Providers: 50 State
Comparison
Appendix 14B Commission on Cancer’s Standard Manual Name Change

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 About the Lead Author

Cheryl Gregg Fahrenholz, RHIA, CCS-P, is the president of Preferred Healthcare Solutions,
LLC, and has more than 30 years of experience working with healthcare facilities, physicians, and
their staff. Her consulting services include revenue cycle integrity management, ICD-10 impact
analysis, multispecialty audits related to documentation and coding, Charge Description Master
(CDM) reviews, Clinical Documentation Improvement (CDI) audits, operational and financial
assessments, coding sessions for physicians and staff, charge capture and charge process redesign,
denial audits, risk and sanction analysis, compliance plan evaluations, electronic health record
selection and implementation, forensic auditing and litigation support, expert testimony, along
with interim or retainer professional support and customized project work.
Before establishing her own consulting firm in 1998, Gregg Fahrenholz served as the direc-
tor of Documentation, Coding and Reimbursement at the Primary Care Networks of Premier
Health Network and as the manager of Information Management at Miami Valley Hospital. Gregg
Fahrenholz holds a bachelor of science in health information management (HIM) from Bowling
Green State University and is an AHIMA-approved ICD-10 trainer.
Gregg Fahrenholz is a nationally recognized speaker on the topics of revenue cycle, documenta-
tion, coding, and compliance. She has published extensively at the national level through books and
peer-reviewed articles on revenue cycle integrity, documentation, and coding. She has co-chaired
AHIMA’s Practice Councils for both the Clinical Coding and Terminology and Physician Practice.
She served on AHIMA’s Nominating Committee and Annual Meeting Planning Committee among
other volunteer opportunities at AHIMA. She served for numerous years on the Ohio Health
Information Management Association board of directors. She received the Triumph Discovery
Award from AHIMA and the Distinguished Member Award from the Ohio Health Information
Management Association and the Miami Valley Health Information Management Association.

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 About the Chapter Contributors

Dilhari R. DeAlmeida, PhD, RHIA, is an assistant professor in the department of Health

Information Management at the University of Pittsburgh. She has a master’s degree in health
information systems and a doctoral degree focusing on documentation improvement in ICD-10.
In addition to her volunteer services for AHIMA, she teaches and advises both undergradu-
ate and graduate students in HIM. Dr. DeAlmeida has published on the topic of data analytics,
eResearch, and clinical decision support systems. She serves as a reviewer for Perspectives in
Health Information Management. Her research interests include electronic health record research
and data analytics in healthcare. She is also an AHIMA-approved ICD-10-CM/PCS trainer.

Thomas J. Hunt, PhD, RHIA, CHDA, FAHIMA, is an assistant professor at Rutgers University
in the School of Health Professions Department of Health Informatics. He previously served as
associate dean and professor of Health Information Management at Davenport University. Before
transitioning to higher education, he was successful in leadership roles with Sparrow Health
System, ProMedica Health System, and Mercy Health Partners. He is a past president of the
Michigan Health Information Management Association (MHIMA) and is also a past president of
the Lake Huron Michigan Health Information Management Association. Dr. Hunt earned a doctor
of philosophy degree in Global Leadership with a concentration in Organizational Management
from Indiana Institute of Technology, a master of business administration from Davenport
University, and undergraduate degrees from Cleary University and Mercy College of Ohio. He has
been a presenter at the International Federation of Health Information Management Associations
(IFHIMA) Congress and General Assembly, AHIMA Convention and Exhibit, AHIMA Assembly
on Education, as well as the MHIMA Annual State Conference.

Ella L. James, MS, RHIT, CPHQ, is the former director of corporate health information man-
agement and health information privacy officer at Hospital for Special Care in New Britain,
Connecticut. Currently, James is an independent ICD-10-CM coding consultant and auditor for
long-term care hospitals across the nation (LTCHs). James is past president of and twice sat on the
board of directors for the Connecticut HIMA and was an AHIMA Community of Practice (CoP)
facilitator for long-term care. She chaired the coding committee for the National Association of
Long Term Hospitals (NALTH). James has presented programs on HIPAA at the state, regional,
and national levels and has presented educational programs for coders and physicians on long-
term acute-care coding for NALTH. She has consulted on coding and documentation issues for
many long-term acute-care hospitals through NALTH. She is the author of Documentation and
Reimbursement for Long-Term Care and contributing author of the AHIMA publication Health
Information Management Compliance and Documentation for Health Records.

Neisa Jenkins, EdD, RHIA, earned her bachelor of arts degree in Health Information Management
at the University of Illinois (Chicago), a master of arts in Health Information Management at the
College of St. Scholastica and her Doctorate of Education at Walden University. She has over 25
years of experience in Health Information Management. Her professional background includes

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 xx About the Chapter Contributors

HEDIS auditing, consulting, quality improvement, utilization management, release of information,

EHR-S implementation, HIPAA implementation, ICD-10-CM/PCS, and teaching in higher edu-
cation. Dr. Jenkins has taught courses in health information management, health service manage-
ment, and healthcare administration. She has held positions as program dean, faculty chair, visiting
professor, and full professor. Dr. Jenkins’s teaching philosophy is borrowed from Martin Luther
King Jr.: “Intelligence plus character—that is the goal of true education” (Martin Luther King Jr.
“The Purpose of Education.” 1947).

Suzanne Paone, MBA, DHA, RHIA, is an accomplished healthcare executive in academic med-
icine including awards by the American Hospital Association and Microsoft. She transverses aca-
demics with 12 years of teaching and curriculum development in analytics, HIM, informatics,
and strategy. She speaks to and advises education, healthcare, and technology companies. Current
research includes Transformational Analytics curricula development. Full-time appointment is at
Ashford University in HIM and dual appointments include: University of Pittsburgh HIM, Pitt
Graduate School of Public Health MHA, and the MBA program at Carlow University. She is the
president of Innovation Advising, a cooperative platform for professional services based in servant
leadership. Suzanne holds several not-for-profit board positions and is published in technology
adoption, eHealth, and health data analytics.

Laurie A. Rinehart-Thompson, JD, RHIA, CHP, FAHIMA, is the director of the health infor-
mation management and systems program and an associate professor at The Ohio State University.
She earned her bachelor of science and juris doctor degrees from The Ohio State University. Her
professional experiences span HIM education, behavioral health, home health, and acute care. She
has served as an expert witness, testifying regarding the privacy of health information. She has
chaired the AHIMA Professional Ethics Committee and has served on numerous AHIMA com-
mittees and the Ohio Health Information Management Association board of directors. She is a
coeditor and coauthor of AHIMA’s Fundamentals of Law for Health Informatics and Information
Management; author of AHIMA’s Introduction to Health Information Privacy and Security; and
a contributing author to numerous HIM textbooks and periodicals. She received the Ohio Health
Information Management Association’s Distinguished Member Award and the AHIMA Legacy
Award in 2010, and she became an AHIMA fellow in 2011.

Susan Rossiter, RHIA, CHPS, has over 30 years’ experience in a variety of settings within
the health information management field. Since 2003, she has been the Health Information
Management operations manager for the University of Texas Southwestern Medical Center, a large
academic medical center located in Dallas, Texas. Prior to that, she was the Hospital Compliance
officer for Terrell State Hospital and has several years of experience in management of HIM depart-
ments for acute care, behavioral health, and ambulatory care organizations. Rossiter graduated
with honors from Texas Woman’s University, where she received the Outstanding Senior Student
in the State award from the Texas Medical Record Association and the Dallas Outstanding Senior
Student award from Texas Woman’s University. In November 2000, she received a Certificate of
Recognition from the Governor’s Commission for Women as one of the Outstanding Women in
Texas Government. As chair for the Executive Women in Texas Government, Dallas Affiliate, she
supports and promotes women in leadership service to the state of Texas.

Lisa Selman-Holman JD, BSN, RN, HCS-D, COS-C, HCS-O, HCS-H, is the owner of Selman-
Holman & Associates, LLC. A 30-year veteran of home care as an RN and as an attorney, she has
participated in the writing of home care regulations and has been involved in accreditation surveys,

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 About the Chapter Contributors xxi

acquisitions, and many regulatory crises. Responsibilities have included risk management, sur-
vey compliance, Medicare appeals, Corrective Action Plans, due diligence audits, consulting with
agencies, and education of staff. Selman-Holman obtained her JD from University of Houston
and her BSN from the University of Tulsa. She is certified as a home care coder and a hospice
coder and is certified in OASIS. She is the chair of the Board of Medical Specialty Coding and
Compliance and an editor of the Decision Health coding manual. She has served on regulatory
task forces and the Quality Improvement Organization for OBQI. Current projects include online
programs through CodePro University and outsource coding through CoDR—Coding Done Right.
She is an AHIMA-approved ICD-10-CM trainer.

Valerie J. Watzlaf, PhD, MPH, RHIA, FAHIMA, is an associate professor in the Department
of Health Information Management (HIM) at the University of Pittsburgh. She has worked as a
HIM practitioner and consulted in several healthcare organizations in HIM, long-term care, and
epidemiology. Dr. Watzlaf has chaired and served on multiple AHIMA committees and boards
such as the Board of Directors of AHIMA and the AHIMA Foundation and chair of the Council for
Excellence in Education (CEE). Dr. Watzlaf was elected as president/chair-elect of AHIMA start-
ing in 2018. She has coauthored the textbook Health Informatics Research Methods: Principles
and Practice. Dr. Watzlaf is also on the editorial advisory board for the Journal of AHIMA and for
Perspectives in HIM. She has delivered over 100 presentations and authored over 50 publications
and is the recipient of numerous awards and professional accolades including the AHIMA Triumph
Award for Research, PHIMA’s Distinguished Member Award, and the University of Pittsburgh’s
SHRS Distinguished Alumnus Award.

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 Acknowledgments

Cheryl Gregg Fahrenholz wishes to thank Ashley Latta, production development editor, for her
detailed eye and continued guidance with this publication. Additionally, she thanks the contribut-
ing authors for sharing their expertise and time in order to produce a comprehensive publication
for HIM readers.
A special thanks from Cheryl to her husband, Mark, and mother, Pat, for their never-ending
support. With all of the challenges in our busy lives, they make it easier to balance professional
and family life in order for this publication journey to be a success.

AHIMA Press would like to acknowledge the following contributors for their work on prior
editions of this textbook.

Kathleen Munn, RHIA

Diana Warner, MA, RHIA, CHPS, FAHIMA
Margaret White, MS, NHA, RHIA, CPHQ

AHIMA Press would also like to thank Ruthann Russo, PhD, MPH, RHIT, for serving as a
volume editor in the prior edition of this text.
Finally, we would like to thank Kathleen M. Kirk, MS, RHIA, CHC, for her review and feed-
back on this text.

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 Introduction

Purpose of Health Record Documentation

The primary focus of a health record is documenting patient care and serving as a mechanism for
sharing information about the patient with other healthcare providers. However, the documentation
of healthcare is used in a myriad of other areas. It:

●● Serves as the primary document for recording a patient’s medical history, treatment plan,
diagnoses, and procedures
●● Serves as the official business record for the provider and facility
●● Is used for billing and reimbursement
●● Is used for secondary data sources, such as registries
●● Is used in research
●● Is used in evaluation of the quality of care
●● Is used for internal and external review of quality of care
●● Is used in the reporting of communicable diseases
●● Is used for establishing healthcare policy and public health
●● Is used in litigation support

When we talk about the purpose of the health record, we think about the documentation of care
rendered to the patient, communication about the patient among providers, and the health record
as the official business and legal record. Although clinical documentation is highly important, the
health record is the primary source of information for secondary uses such as clinical research,
public health reporting, and fraud detection and deterrence. As legislative acts focusing on specific
topics were passed, the administrative guidelines often reflected guidelines or requirements for
health record content. See table I.1.

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 2 Introduction

Table I.1. Selected milestones that shaped healthcare, the health information
profession, and the health record

YEAR MILESTONE

1798 An act was passed for the relief of sick and disabled seamen. This act established a federal
network of hospitals for the care of merchant seamen and was the forerunner of today’s US
Public Health Service (PHS).

1862 President Lincoln appointed chemist Charles M. Wetherill to serve in the new Department of
Agriculture. This was the beginning of the Bureau of Chemistry, forerunner to the Food and Drug
Administration (FDA).

1871 The first supervising surgeon (now called surgeon general) was appointed for the Marine
Hospital Service, which was organized the prior year.

1887 The federal government opened a one-room laboratory on Staten Island, NY, for research on
disease, thereby planting the seed that grew into the National Institutes of Health (NIH).

1902 The Marine Hospital Service was converted into the Public Health and Marine Hospital Service
in recognition of its expanding activities in the field of public health. In 1912, the name was
shortened to the Public Health Service.

1906 Congress passed the Pure Food and Drugs Act, authorizing the government to monitor the
purity of foods and the safety of medicines, now a responsibility of the FDA.

1910 Hospitals began to track every patient treated long enough to determine whether the treatment
was effective. If the treatment was not effective, the hospital would then attempt to determine
why, so that similar cases could be treated successfully in the future.

1921 The Bureau of Indian Affairs Health Division was created, the forerunner to the Indian Health
Service.

1928 The Association of Record Librarians of North America was created. This organization is now the
American Health Information Management Association (AHIMA).

1930 The National Institute (later renamed Institutes) of Health was created out of the Public Health
Service’s Hygienic Laboratory.

1935 The Social Security Act passed.

1938 The federal Food, Drug, and Cosmetic Act passed.

1939 The Federal Security Agency was created, bringing together related federal activities in the fields
of health, education, and social insurance.

1946 The Communicable Disease Center was established, forerunner of the Centers for Disease
Control and Prevention (CDC).

1951 The American College of Physicians (ACP), the American Hospital Association (AHA), the
American Medical Association (AMA), and the Canadian Medical Association (CMA) joined
with the American College of Surgeons (ACS) to create the Joint Commission on Accreditation
of Hospitals (JCAHO, later renamed The Joint Commission), an independent, not-for-profit
organization whose primary purpose is to provide voluntary accreditation.

1955 The Salk polio vaccine was licensed.

The Indian Health Service was transferred to the Department of Health and Human Services
(HHS) from the Department of Interior.

(Continued)

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 Purpose of Health Record Documentation 3

Table I.1. Selected milestones that shaped healthcare, the health information
profession, and the health record (Continued)

YEAR MILESTONE

1961 The first White House Conference on Aging was held.

1962 The Migrant Health Act passed, providing support for clinics serving agricultural workers.

1964 The first Surgeon General’s Report on Smoking and Health was released.

1965 The Medicare and Medicaid programs were created, making comprehensive healthcare available
to millions of Americans.
The Older Americans Act created the nutritional and social programs administered by HHS
Administration on Aging.
The Head Start program was created.

1966 Led by the US Public Health Service, the International Smallpox Eradication program was
established. The worldwide eradication of smallpox was accomplished in 1977.
The Community Health Center and Migrant Health Center programs were launched.

1970 The National Health Service Corps was created.

The Association of Record Librarians became the American Medical Record Association (AMRA),
which is now AHIMA.

1971 The National Cancer Act was signed into law.

1977 The Health Care Financing Administration (HCFA) was created to manage Medicare and
Medicaid separately from the Social Security Administration.

1980 The federal government began funding to states for foster care and adoption assistance.

1981 Acquired immunodeficiency syndrome (AIDS) was identified in the United States. In 1984, the
human immunodeficiency virus (HIV) was identified by PHS and French scientists. In 1985, a
blood test to detect HIV was licensed.

1982 Congress mandated the development of a prospective payment system (PPS) to efficiently
manage healthcare costs. This system is a per-case reimbursement mechanism in which inpatient
admissions are divided into relatively homogeneous categories called diagnosis-related groups
(DRGs).

1984 The National Organ Transplantation Act was signed into law.

1986 The Consolidated Omnibus Budget Reconciliation Act (COBRA) required employers to offer
partially subsidized health insurance to employees who lost their jobs.

1989 The Agency for Health Care Policy and Research (now the Agency for Healthcare Research and
Quality [AHRQ]) was created.

1990 The Human Genome Project was established.

The Nutrition Labeling and Education Act was passed, authorizing packaged food labeling.
The Ryan White Comprehensive AIDS Resource Emergency (CARE) Act began providing support
for people with AIDS.

1991 AMRA became AHIMA.

(Continued)

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 4 Introduction

Table I.1. Selected milestones that shaped healthcare, the health information
profession, and the health record (Continued)

YEAR MILESTONE

1994 The Vaccine for Children Program was created to provide free vaccines to children in low-income
families.

1996 Welfare reform was enacted under the Personal Responsibility and Work Opportunity
Reconciliation Act.
The Health Insurance Portability and Accountability Act (HIPAA) was enacted.

1997 The State Children’s Health Insurance Program (SCHIP) was created, enabling states to extend
health coverage to more uninsured children.

2000 The human genome sequencing was published.

2001 The Centers for Medicare and Medicaid (CMS) was created, replacing HCFA.
HHS responds to the nation’s first bioterrorism attack—the delivery of anthrax through the mail.

2002 The Office of Public Health Emergency Preparedness was created to coordinate efforts against
bioterrorism and other emergency health threats.

2003 The Medicare Prescription Drug, Improvement and Modernization Act, enacted in 2003,
brought Medicare Part D coverage for seniors’ prescription drugs through private insurance
plans.

2004 The Office of the National Coordinator for Health Information Technology (ONCHIT, now
abbreviated ONC) was created.

2009 The American Recovery and Reinvestment Act (ARRA) of 2009 was passed. This act includes
the Health Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009,
which includes components that define Medicare and Medicaid incentive payments; introduces
meaningful use (MU) for certified electronic health records (EHRs); and addresses confidentiality,
privacy, and security standards.

2010 The healthcare reform bill, Health Care and Education Reconciliation Act, passed.

2012 Incentives for physicians who participated in accountable care organizations were established
through the Accountable Care Act.

2013 The Bundled Payments for Care Improvement initiative was developed by the Center for
Medicare and Medicaid Services. This payment provision allowed acute-care hospitals and
other providers to enter into payment arrangements, which includes performance and financial
accountability for each patient’s episodes of care.

2014 Healthcare reform requires minimum insurance coverage be obtained by each person or a tax
paid.

2015 International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System
(ICD-10-CM/PCS) is implemented in the United States.

2016 As part of the Affordable Care Act, employer requirements were altered to define specific
insurance coverage that must be offered to employees. Midsized employers with 50–99
employees are now included along with large employers with 100 or more employees.

(Continued)

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Another random document with
no related content on Scribd:
 St John’s College, 160, 200
Oxford, printing, 1, 2, 41, 79, 187;
booksellers, 69, 77, 98, 161, 196;
bindings, 103, 104

Paffroed, R., 79
Palsgrave, J., L’eclarcissement de la langue Française, 166
Panzer, G. W., 217
Paper-making in England, 29
Paris printing, 17, 18, 84, 85, 87, 96, 97, 161, 193, 194, 195, 196,
199, 205, 210, 214
Paris and Vienne, G. Leeu, 88
Parker, H., Dives and Pauper, Pynson, 1493, 54, 61
Parliament of Devils, W. de Worde, 135
Parron, William, 68
Parson of Kalenborowe, J. van Doesborch, 220, 221
Parvula, N. Marcant, 84
Parvulorum institutio, J. Butler, 1529, 152
Passio Jesu Christi, Strasburg, 1506, 211
Passion of our Lord (ab. 1508), 211
Pastime of People, J. Rastell, 184
Paule, Michael de, 207
Paynell, T., Assault and Conquest of Heaven, 1529, 178;
trans. of Regimen sanitatis Salerni, T. Berthelet, 177, 178
Pelgrim, Joyce, 193-198, 232
Penketh, Thomas, 42
Pepwell, Arthur, 150
Pepwell, Henry, 139, 147-150, 199, 202
Pepwell, Ursula, 149
Pepysian Library. See Cambridge libraries
Perez de Valentia, J., 42
Perott, N., Regulae Grammaticales, Louvain, 77
Peter Post Pascha, 66, 67, 93
Peterborough Cathedral Library, 132
Petyt, Thomas, 176
Pigouchet, Philippe, 115, 205
Pilgrimage of Sir Richard Guylforde, Pynson, 1511, 163
Play concerning Lucretia, J. Rastell, 185
Poitevin, Jean, 86
Pollard, John, 235
Pomander of Prayer, R. Redman, 175
Powell, Thomas, 181, 183
Prevost, Nicolas, 199, 205
Prices of paper and printing, 169, 179
Processional, Sarum, Pynson, 1502, 160;
N. Prevost, 1530, 218;
C. van Ruremond, 1523, 222, 225-6;
Antwerp, for J. Reynes, 200
Proclamation on the coinage, W. Faques, 1504, 169
Proclamations, T. Berthelet, 179
Proctor, R., 17, 125, 196
Prognostications, 68, 226-7
Promise of Matrimony, Machlinia, 48, 51
Promptorium parvulorum, 67
Promptorius puerorum, Pynson, 1499, 66, 93
Propositio Johannis Russell, Caxton, 4, 9
Prymer, J. Byddell, 1535, 204
Psalter, Latin, Caxton, 13;
W. Faques, 1504, 169, 170
Psalter, Sarum, C. van Ruremond, 226
Psalterium beate marie virginis, S. Voster, 210
Psalterium cum hymnis, 1507, 194;
1530, 199
Pudsey, Bishop, 102
Pynson, Margaret, 166
Pynson, R., 55-71, 158-169, 173, 174, 177, 189, 206, 235, 236
Arms, 162
Bindings, 109, 113-115, 165, 232
Borders, 49, 56, 176
Books printed by, 93, 124, 145, 195
Devices, 59, 62, 65, 174
King’s printer, 133, 162, 171
Method of dating, 68, 159, 160
Printing office, 40, 71, 141, 158, 159, 173
Types, 58, 60, 61, 62, 70
Woodcuts, 57, 62, 64
Pynson, R., junior, 166, 177

Quarto leaves in a folio volume, 52

Quatre derrenières choses, Caxton, 6
Quattuor Sermones. See Mirk, J., Liber Festivalis
Quentell, H., 65, 79

R., A., bookbinder, 116

R., G., bookbinder, 233
R., P., device, 83
Raimund, John. See Ruremond, Hans van
Rastell, Elizabeth, 183
Rastell, John, 152, 156, 158, 183-186, 203;
New Boke of Purgatory, 184
Rastell, John, junior, 185
Rastell, William, 158, 180, 185, 186
Ratcliffe, John, 79, 162
Ravynell, James, 83
Rawlinson Collection, 134
Recuyell of the Historyes of Troye, Caxton, 3, 6
Redman, Elizabeth, 176
Redman, John, 125, 177
Redman, Robert, 155, 158, 165, 172-177, 203
Regnault, Francis, 207-209
Regula Benedicti, W. de Worde for Jacobi, 196
Regulae et ordinationes, Machlinia, 55
Rembolt, Berthold, 87, 205
Remonde. See Ruremond
Revelation of St Nicholas, Machlinia, 48, 50
Reynard the Fox, Caxton, 13;
W. de Worde, 37
Reynes, John, 119, 193, 199-202, 219;
bindings, 232-234
Reynes, Lucy, 201, 202
Richard, Jean, 81, 82, 205, 207
Richard Cœur de Lion, W. de Worde, 1509, 135
Richardson, John, 235
Richmond, Countess of, 133, 134
Ripon Cathedral Library, 70, 159
Rivers, Earl, 6
Robin Hood, J. van Doesborch, 220
Roce, Denis, 150
Rolle, Richard. See Hampole, Richard de
Rome, 41
Rood, Theodore, 104
Rosary, J. Skot, 1537, 151
Rosse, Denis, 150
Rote or mirror of consolation, W. de Worde, 33, 34
Rouen: printing, 37, 55, 80, 82, 83, 204-6, 214;
bindings, 233
Rouse, John, 235
Row, John, bookbinder, 224, 235
Roxburghe sale, 35, 39
Royal Book, Caxton, 16, 106
Rue, Andrew, 193
Rue, John, 193
Rule of St Benet, Caxton, 21;
Pynson, 160
Rupertus, De victoria verbi Dei, 1541, 219
Ruremond, C. van, 130, 200, 222-227, 230;
Widow of, 230
Ruremond, Hans van, 218, 222-7
Russell, J., bp of Lincoln, 4

St Alban’s, printing, 41, 149, 187;

 binding, 109
St Alban’s Grammar School Library, 106, 107
St Andrews printing, 151
Saint Germain, C., Answer, 157;
Division, 175, 180;
Dialogue, 180
St Paul’s Churchyard, 191
Savonarola, Sermo, R. Pynson, 1509, 163;
Tracts, H. Jacobi, 1510, 198
Sayle, C. E., 228, 239
Scala Perfectionis, J. Notary, 1508, 143
“Scales” binder, 110
Schoeffer, J., 229
Schoiffer, P., 4
Scotland, introduction of printing, 7
Scott, E. J. L., 130
Scriptores rei rusticae, Reggio, 1496, 80
Sedley, John, 194
Selden, John, 106
Sermo pro episcopo puerorum, W. de Worde, 28
Sermones dormi secure, 193
Service books printed abroad for the English market, 78, 80-82,
84-87, 91-93, 205-210, 212-213, 222, 225, 226
Seven Points of True Love, Caxton, 21
Seven wise masters of Rome, W. de Worde, 36
Sex quam elegantissimae epistolae, Caxton, 14
Shepherdes Calendar, 145
Shirburn Castle Library, 184
Short treatyse (Margerie Kempe), W. de Worde, 132
Shrewsbury School Library, 133
Siberch, John, 99, 130, 226
Siege of Rhodes, 45
Signatures first used, 3;
in England, 11
Signs:
A.B.C., R. Faques, 171
Fat Hen, Birckman, 219
George, Pynson, 71, 159, 173;
R. Redman, 173
Golden Cross, L. Andrewe, 155
Golden Missal, A. van Berghen, 215
Great Golden Mortar, A. van Berghen, 215
Iron Balance, R. van den Dorp, J. van Doesborch, 220
Lucrece, T. Berthelet, 178
Maiden’s Head, R. Faques, 171, 234
Mermaid, J. Rastell, 144, 184
Our Lady of Pity, W. de Worde, 135;
J. Byddell, 144;
J. Redman, 177
Red Pale, Caxton, 6
Rose Garland, R. Copland, 146, 147
St Anne, J. Pelgrim, 195
St John Evangelist, G. Chasteleyn, 69;
J. Butler, 152;
R. Wyer, 156
St Katherine, 198
St Mark, J. Notary, 144
St Nicholas, N. Lecomte, 95;
J. Toy, 153
Striped Ass, P. de Couvelance, 198, 199
Sun, W. de Worde, 33, 131, 146;
 J. Byddell, 140, 144;
J. Gaver, 140
Three Kings, J. Notary, 141, 143, 144
Trinity, 198, 199;
H. Pepwell, 147;
H. Jacobi, 148, 195;
H. Smith, 176
Wodows, P. Treveris, 115
Silverlink, John, 218
Singer, S. W., 2
Sirectus, Antonius, Formalitates, 196
Sizes of books, 49
Skelton, John, 64;
Bowge of Court, W. de Worde, 37;
Magnificence, J. Rastell, 185
Skot, John, 137, 138, 150-53
Smarte, Epitaph of Jasper, Duke of Bedford, Pynson, 63
Smith, Henry, 176
Smith, Richard, 142, 149
Smyth, Thomas, 154, 155
Snowe, John, 166
Society of Antiquaries Library, 55, 102, 155
Solomon and Marcolphus, G. Leeu, 88, 89
Southwark printing, 177, 199, 208
Speculum Christiani, Machlinia, 53, 77
Speculum Spiritualium, W. Hopyl, 1510, 194
Speculum vitae Christi. See Bonaventura
Spencer, Earl, 8, 16, 74.
See also Althorp Library
Spering, Nicolas, 117, 120, 216
Spiritus Guidonis (Pynson), 59
Squire, Henry, 158, 189
Stanbridge, John, 79, 206;
Accidence, J. Gaver, 140;
J. Skot, 150;
Shorter Accidence, 1534, 153
Stans Puer ad Mensam, 10
Statham, N., Abridgement, Rouen, for Pynson, 57
Stationer, business of, 72, 76
Stationer to the King, 1485, 77
Stationer, University, at Oxford, 77
Stationers:
foreign, in England, 54;
fifteenth century, 72-100;
of London, 187-213;
aliens, 187-191;
from Antwerp, 214-231
Stationers’ Company, 76, 94, 95, 148, 188, 189, 227
Statutes first written in English, 56
Statutes, Machlinia, 54;
W. Faques, 169, 170;
T. Berthelet, 178
Statutes of War, Pynson, 1513, 163
Stewarde, William, 141
Stewart, W., bp of Aberdeen, 124
Stillingfleet, Bishop, 143
Stoke, Thomas, 235
Stokeslay, Bishop, 148, 149
Stondo, Bernard van, 53, 77
Stonyhurst Library, 32, 161
Storys and prophesis, S. Cock, 1536, 231
Strasburg printing, 211
Strype, John, 191
Sturbridge fair, 192
Suethon, Ludovicus, 199, 202
Sulpitius, J., Grammar, W. de Worde, 1504, 133
Sutherland, Duke of, 38
Sutton, Edward, 201
Sutton, Lewis, 148, 199, 202-3
Sutton, Nicholas, 154, 203
Sykes sale, 40
Symmen, Henric van, 90
Symonds, Thomas, 192, 202

Tab, Henry, 149

Tanner, Thomas, 11, 90
Tate, J., papermaker, 29
Taverner, John, 193, 194
Taverner, Richard, 154
Temple of Brass, Caxton, 10
Temple of Glas, Caxton, 10
Terentius, Pynson, 66;
Paris, 1504, 206;
Hecyra, Pynson, 1495, 63;
Vulgaria, Machlinia, 48, 51, 54;
G. Leeu, 78;
 Oxford, 79;
W. Faques, 170
Three Kings of Cologne, W. de Worde, 28, 34, 90
Thwaytes, Edward, 151
Thynne, William, 156
Tindale, W., 228, 229, 230
Title-page, first English, 53;
first Westminster, 25
Title-pages, Collection of, in British Museum, 8
Toy, John, 150, 153, 154, 203
Treatise of Love, W. de Worde, 24, 25
Tree and xii frutes of the holy goost, 172
Treveris, Peter, 115, 156, 199, 216
Trevisa, John, 29
Trinity stationers. See Jacobi, Henry; Pelgrim, Joyce
Triphook, bookseller, 53
Troost, Ian, 228
Troylus and Cressede, W. de Worde, 1517, 137
Tuke, Sir Brian, 156
Tunstall, C., De arte supputandi, Pynson, 1522, 165
Twelve Profits of Tribulation, Caxton, 21
Tyl Howleglas. See Howleglas
Type, side impression of, 216

Ulmer, Johann, 219

Upsala University Library, 11
Utrecht printing, 5, 217
Valuation of gold and silver, J. van Doesborch, 155, 221
Vanduffle, Woter, 112
Vatican Library, 164
Vaughan, Stephen, 168
Veldener, J., 5, 52, 54
Vellum, books printed on, 20, 30, 68, 73, 125, 134, 136, 137, 150,
160-5, 170, 180, 181, 204, 209
Venice printing, 73, 85, 91, 93
Verard, Antoine, 145, 161, 206, 212
Vergilius, Eneydos, Caxton, 20;
Life of, J. van Doesborch, 220, 221
Very declaration of the ... will of man, St Alban’s, 149
Violette, Pierre, 205, 206, 207
Vitas Patrum, W. de Worde, 1495, 28
Voragine, J. de, Golden Legend, Caxton, 15, 18, 23, 24;
W. de Worde, 24, 25, 30, 31, 135, 141;
Notary, 31, 141;
Pynson, 162
Voster, Simon, 210
Vrankenbergh, H., 53

Wakefield, R., Kotser codicis, T. Berthelet, 178

Wallensis, T., Expositiones super Psalterium, Lettou, 42, 43, 108
Wallis, Thomas, 193
Walsingham, Foundation of Our Lady’s Chapel, Pynson, 63, 64
Wanseford, Gerard, 94
Warde, son-in-law to Pynson, 166
Watson, Henry, 135, 136
Watton, John, 53
Way, Albert, 67
Way to the Holy Land, W. de Worde, 137
Waynflete, William, 79
Weale, W. H. J., 111
Wednesday’s Fast, W. de Worde, 8
Wenssler, Michael, 78
Westminster Abbey Library, 68, 99, 103, 113, 125, 148, 212, 226
Westminster printing, 1-40, 187
Whitchurch, Edward, 208, 209
Whitford, R., Dayly Exercise, R. Redman, 175
Whitinton, R., Grammar, W. de Worde, 124, 137;
Pynson, 1515, 62;
Vulgaria, Pynson, 1520, 177
Wilcock, William, 42, 45
Willett sale, 61
Winchester bindings, 102-104
Winchester Domesday Book, 102
Windsor, Royal Library, 20, 81
Wislyn, John, 139
Withers, Richard, 166
Wolsey, Cardinal, 164, 224
Wonderful shape and nature, J. van Doesborch, 155, 221
Wood, Anthony á, 178
Woodcut of Crucifixion, 21, 27, 33, 132-3
Woodcuts, 12, 57, 62, 64, 86, 88, 89, 91, 135, 141, 154, 156, 162,
172, 184, 194, 199, 211
Worde, Elizabeth de, 130, 139
Worde, W. de, 23-38, 56, 129-141, 146-7, 149, 150, 152, 162,
178, 199, 235
Bindings, 107, 108, 113, 139, 140, 197
Books printed by, 4, 7, 8, 90, 124, 145, 196, 207, 212
Death, 138
Devices, 25, 26, 32, 132, 133, 212
Method of dating, 31, 135, 141
Number of books printed, 34, 137
Printer to the King’s mother, 133-4
Printing office and shop, 33, 131, 135
Quarto tracts, 32
Removal to London, 33, 131
Types, 19, 24, 25, 26, 30, 131
Woodcuts, 26, 27, 28, 29, 30, 32, 33, 36, 37, 131, 133, 135, 142
Wright, Edward, 201
Wyer, Robert, 156, 203

Year-books, Lettou and Machlinia, 44;

Pynson, 57, 59
Yonge, John, 198
York, printing, 87;
stationer, 94

Zel, Ulric, 142

CAMBRIDGE: PRINTED BY JOHN CLAY, M.A., AT THE UNIVERSITY PRESS.

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