As an integral part of the healthcare team, the HIM department is responsible for providing services to the healthcare industry and the general public through the efficient management, analysis, and utility of data necessary for the optimal delivery of services to patients. This data is saved and made available at an appropriate time when it is required by healthcare providers.
Content and Flow of health records of patients
Records of patients’ health status begin with retrieval and tracking, followed by scanning into the electronic database for availability to physicians as and when needed.
Health Information of patients is systematically maintained by assigning unique medical record numbers to every patient. Information data includes the documentation related to admission, advance directives and consent forms, history of physical examinations, and all other vital information recorded during investigations including assessments, MDS, care plan, physician orders, history of consultation, progress notes, all documentation related to nursing, medication and treatment plans, laboratory reports such as x-rays, diagnostic tests, nutritional documents, and any other data which may have been taken during the course of healthcare service delivery to patients.
Software application for processing, accessing and maintenance of information
The system used to process, access and maintain healthcare records and information of patients is based on multiple systems in accordance with the Joint Commission on Accreditation of Healthcare Organization (JCAHO) which emphasizes all H&P operations to occur within 24 hours, failing which physicians could be suspended. All data and information is electronic and computerized and necessitates imaging once the patient is discharged. Access and retention of patient data and health records is under severe security rights and most retention is highly secure and can be done through the electronic medium. All health information on paper is destroyed within four months and there are stringent checks to affirm this.
The Health Insurance Portability and Accountability Act (HIPAA) is strictly adhered to and determines the confidentiality, privacy and security policies and procedures with regard to the acquiring, transfer and maintenance of health data of patients. Additionally, the SV541 and AB211 are being updated under new laws.
HIM Department- Organization structure and Employee Strength
The total employee strength of the HIM department is 60 which includes directors, supervisors, contract coders and outside service providers for copying records.
One employee, the Coding Manager, has the credential of RHIA while 10 others have the RHIT credentials.
The department includes clerical staff members who have received cross-training in multiple domains of information management including prepping, scanning, filing and analyzing data. The filing/ scanning department comprises about 10 staff members.
The release of information has been contracted with outside service staff in addition to the existing 10 to 12 staff members in the medical records department. Records are maintained using an appropriate software solution, for instance, coding enables reimbursement and data collection and the storing of data is accomplished through the system of Master Patient Index which grants specific code numbers to individual patient records. The filing and numbering systems also enable quick recovery of information and data when needed.
Health record Description
All health records are described out of title 22 and in accordance with the CA hospital consent manual. 75% of the records are maintained on paper while 25% are electronic files. These include Labs-rays, physician and nursing documentation which are on paper but can also be generated electronically through the use of a software called the IBEX. The software is interfaced into a system called Document Imaging (DI). Once the records are scanned into the DI, they can be viewed online by a healthcare professional from their respective departments.
The extent of Electronic health records (EHR)
Testing is conducted through the EHR system for clinical and documentary purposes except in the case of physicians looking at the order entry. The OB women centre, Fetal monitoring, nursing documents are all electronically maintained while hard copies of fetal development are also maintained in physical format.
Policies for retaining medical records
All records are scanned into the computer through DI and are stored for 3 months following which the correspondence and copying services purge the records and move them securely from the system to a site facility called the Iron Mountain.
Hard copies are maintained in the department for a maximum of 3 months and in the Iron Mountain site for 10 years where they are then eliminated by a letter of destruction.
Enforcement of HIPAA
The federal HIPAA law is followed very seriously in the organization and all measures are taken to ensure patient privacy rights. Access to patient information charts is strictly restricted to the concerned staff members only and information is never transferred over the phone. Patient health information can only be accessed by physicians and professionals requiring medical records for patient healthcare purposes. HIPAA is also strictly enforced in the Department of Health and Human Services (DHS) so that in most cases patients require written permission to request a release of records except in cases where law enforcement or court order is necessary.
In the HIM department, HIPAA is enforced through strict quality control measures, checks and balances. Tracking of computer usage and frequency of review of cases online is restricted nu a secure network sign for each individual including physicians, who are required to login through a unique protected username and password. Violation of the HIPAA law results in strict fines or penalties and some cases even termination of employees found guilty.
Letter of Thanks
The faculty and staff of HIM,
Date: 13th April, 2009
Subject: Letter of thanks.
Dear Staff and faculty members,
I take this opportunity to thank each and every one of you, especially the staff members of the HIM Department, who have extended their kind support in the drafting of this report. I am extremely grateful to all the staff members who have lent their valuable time and patience in answering the interview questions, through authentic and reliable data for the report. It was indeed a great pleasure interacting with the cooperative staff members during the course of the interview, without which this report would not have been possible.
Thanks and Regards,