Medical Records & Health Information Management Department
The Health Information Management Department manages the records of all patients seen at the facility. This department maintains records on inpatient, ambulatory surgery, observation, emergency room, and diagnostic testing admissions. The record includes all the information obtained from the patient concerning his or her symptoms and medical history as well as documentation from the physician(s), nursing staff, laboratory tests, radiology (x-ray) test, respiratory test, diagnosis, and treatment plans. The HIM department organizes and evaluates these records for completeness and accuracy. There are several areas of expertise within the department which includes: Assembly Processing, Release of Information, Transcription, Tumor Registry, and Coding. The HIM department is also responsible for reporting to several regulatory agencies.
The clerks within the department have the expertise of chart assembly and deficiency. They are responsible for analyzing the charts for completeness. Each chart is checked to ensure that all forms are completed properly and signed appropriately by the staff and physician(s). The clerks also give service to our walk in customers who request information from their charts. These employees are trained in the area of release of information. The clerks also complete birth certificates, fetal death certificates, maintain life link quarterly reports, completes physician incomplete chart stats and a variety of other duties.
Although the HIM staff has training in the area of release of information our facility utilizes a copying service for release of information. The copying service personnel are available three days a week to copy any request received in the HIM department. There is a fee assessed to the release of information based on the information copied. We receive a variety of request which includes but not limited to request from patients, the business office, attorneys, and insurance companies.
The transcriptionists are skilled personnel in typing and anatomy and physiology. They transcribe reports dictated by the physicians. These reports include emergency room notes, discharge summaries, history and physicals, consultation reports, operative reports, and radiology reports. The transcriptionists work closely with our physicians and staff to assure that the reports are on the charts in a timely manner.
The coding personnel assign codes to the episodes for each patient encounter. The coders use their expert knowledge of the disease process, anatomy and physiology, and their coding skills to code each patient encounter to the appropriate code assignment. Through the computer software used by the facility a DRG (diagnosis-related group) or and APC (Ambulatory Payment Classification) is assigned which determines the amount for which the hospital will be reimbursed if the third party payer uses the DRG or APC system.