Medical Records Procedure Manual

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Happy Health Medical Records Procedure Manual

Sunday, October 10, 2010
Lisa Israel, MBA, CMT

Happy Health Medical Clinic
Medical Records Procedure Manual
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 master patient index (MPI). HID primarily provides patient records for the medical staff and the radiology department. It is HIDs responsibility to maintain professional and ethical standards of confidentiality. All staff at HHMC must follow the professional and ethical standards of confidentiality as a condition of employment. Any staff member who handles patient case files share in the responsibility for their care and confidentiality. Compliance to confidentiality guidelines is mandatory. If compliance is not met, disciplinary action will be taken which could lead to termination of employment.

Security of Health Information

HID department is accessed by authorized staff members only. Patient information located outside of HID must be protected and in secured areas. These areas are analyzed and evaluated every three months for potential breeches of patient privacy and information security.

Original records may not be removed from HHMC except by court order, subpoena, or as otherwise required by law.

The information contained within the Medical Record must be accessible to the patient and thus made available to the patient and/or their legal representative upon appropriate request and authorization by the patient or his or her legal representative (University of California, 2008).

Automated Master Patient Index

A master patient index (MPI) is maintained in the HID database with access by authorized HHMC personnel only. Each authorized user will be given an access code that allows them to access the MPI. New patient information is entered by HHMC provider. Patient information is verified and updated at the time of each visit by the provider. Information to verify or enter: 1. Name

2. Address
3. Birthdate
4. Insurance information
5. SSN

Creating New Records

Each patient who is treated HHMC will have a single file. The file is a tabbed folder labeled with the patient’s first and middle initials and last name. The patient file contains material from every clinical specialty (including radiology) for which the patient has been seen from this facility. The patient is registered on the first visit to the clinic in the MPI and whenever they are seen again as a patient, the same single set of case notes must be made available to clinical staff. Patient records will contain front to back:

1. Face Sheet-stapled to left side of file folder
2. Provider SOAP notes
3. Test results including lab, x-ray, etc.
4. Consultation reports
5. Copied Identification stapled to right side of file folder

These sections are separated by labeled tabbed file dividers.

Duplicated or Lost Records

It is important to avoid duplication of records but if a duplicate record is thought to be found verification is performed by verifying:

1. Name
2. Birthdate
3. Social Security Number

It is then up to the HID staff to merge both files and update MPI index with correct personnel information.

Lost Records/Temporary Folder
1. Temporary folder will be created with all loose filing documents included in temporary folder. 2. A temporary face sheet will be stapled to front of file jacket notating...
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