The Health Information Management Department performs a diverse array of tasks, including transcription, coding, analysis, quality review indexing, birth certificates and maintains the traumatic brain injury and tumor registry.
What happens to a medical record after a patient has an encounter at NorthCrest Medical Center?
First the record is checked for completeness, that all medical information in the folder. Then the information is “coded”. Those codes are transmitted to the third party payers for billing and to state agencies for the collection of aggregate data.
The record is filed in the department. The personal and identifying information is kept confidential through all transmissions. The records are kept locked unless personnel are in the department working.
If a patient needs a copy of their medical record, it is available to them under certain legal procedures. The patient or the patient’s legal guardian must sign a permission to release the record. There may be a small charge for copying the record. Records can be obtained during regular office hours.
The department is open from 7:00am to 5:00 pm Monday through Friday. There are 24 employees who process 225 outpatient records daily and 450 inpatient records monthly.
Medical records are kept for a predetermined period of time depending on what the law requires. The records may be transferred to an electronic form for storage and retrieval.
The record maintenance and data collection role of this department play an important part in the healthcare of the American consumer.