Medical Records Procedure Manual

1466 Words Oct 30th, 2010 6 Pages
Happy Health Medical Records Procedure Manual

HCR/210
Sunday, October 10, 2010
Lisa Israel, MBA, CMT

Happy Health Medical Clinic
Medical Records Procedure Manual
Purpose
To establish guidelines for the maintenance and confidentiality of all patients’ protected health information (PHI) by adhering to federal and state laws and regulations whether those records are paper or electronic. This manual is to be used to train key personal in information management during departmental training.
Medical Records Compliance
Happy Health Medical Clinic (HHMC) Health Information Department (HID) is an on-site centralized filing system. The HID is responsible for the collection and maintenance of confidential and identifiable patient information in a
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Filing System
HHMC utilizes an alphabetical combination centralized/decentralized filing system. Every record handled by the facility is located in HID unless it is in current use by one of the providers or the Radiology department. After patient is seen by provider and progress notes are recorded by the provider, the record is sent to HID for chart filing.
Loose reports that come to HID must be stamped with date of arrival. Loose reports will be filed in chart unless chart is checked out to provider at which time the report will be separated by provider, put into a provider folder and a provider staff member will pickup reports in the morning with requisitioned files. Loose reports returned to HID will be filed within 24 hours. Organizing and filing loose reports within 24 hours allows for quick access to the results that may be needed by the provider. Chronology is essential and close attention shall be given to assure that documents are filed properly and that information is entered in the correct encounter record for the correct patient (University of California, 2008).
Chart Tracking
Provider Requests. The Health Information Management Services staff will process routine requests for Medical Records. All charts physically removed from the Medical Record storage areas will be logged using requisitions forms made out in triplicate. Only authorized HID workforce members may access the medical records in HID. Requisition forms are to have: 1.

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