Assembling Charts

Properly assemble inpatient. Assembly of medical records are done in * Chronological order according to “filing order of the medical record.” * Assemble forms according to the order given in this policy * Charts are identified with typewritten white labels with: 1) Patient Name

2) Electronic Health Record Number (MRN) Order of Chart Assemble 1. Face sheet * Patient Information and Guarantor 2. Consent Forms * Signed Yearly Consent Form * Medicare Consent Forms * Counseling Form * BC Consent

3. Lab Reports * Pathology Reports * Laboratory Reports 4. Prenatal (Only Pregnant Patients) 5. Hospital DC * All hospital discharges including ER visits 6. Cardiac * Echocardiography results * 12-Lead EKGs * Stress Test Results * Cardiac catherization results * Venous & / or Arterial Duplex results * All other heart related 7. Procedures * Biopsy * Op reports (colonoscopy, cholecystectomy, CABG, etc) * All procedures * Home Health Orders 8. Correspondence * Letters from consulting physicians 9. Medical History (Old Records) 10. Miscellaneous

I got to watch Mrs. Cathy as she reviewed charts for deficiencies. If any deficiencies are noted a note is put on the chart and the chart is returned to the physician to have all documentation correct or signed.

At 11 o’clock we had a staff meeting where all the staff, even those that work from home comes in and we reviewed VEH growth, scores, and what the department needs to be doing in the up coming weeks.

After lunch we started reviewing CD’s that have been created from past paper charts. The paper charts have been put on CD to help conserve space, and create a more secure source for saving ad storing past medical histories.

1. X-Rays * All X-Rays * Mammogram * CT Scans, MRIs * Ultrasound * Nuclear Medicine test results * IVPs * DEXA scans * Thyroid scans 2. Referrals * All documentation for referral of patients to outside providers 3. Communication * Orange Telephone Message / Intake Sheets * Any Provider to patient communication including: i. Letters of Missed appointments / no shows ii. Letters of Patient Termination 4. HIPAA * Al Consents – Treatment, Release of Information & Authorization 5. Patient Info / Billing * Patient demographics * CAP information * Insurance information including copies of insurance cards It is important that all documentation such as spelling of the names, addresses of the parents, and full names of the parent are correct the final submitted document. It is a costly mistake for the parents to have to change this information later after submission.

This is where HIPAA polices come into effect and help healthcare personal to maintain administrative, physical and technical safeguards in protect confidentiality and prevent unauthorized access to health information. It was interesting to learn that any if a mother is not married, and the father is not present when signing the application for a birth certificate that he must pay to add his name after the birth certificate has been filed with the NC Birth Certificate Registry. Ms. Boyd has 4 days to submit Birth and Death Certificates to the Edgecombe County Health Department

After numerous trips to verify that all the information was correct on the birth certificates, Ms. Boyd took the time to go over all department policies and procedures for the Release of Information. It is the Health Information’s professional’s responsibility to make sure that private information is not release into the wrong hands. Failure to do so affects department’s credibility in performance and security of information. Guidelines for ROI

Reviews the Authorization form to ensure: • Specific records are requested (general statements such as “all mental health Information” or “all medical records” are not HIPAA compliant) • Clearly specific reason for the released record

• Expiration date • Youth has initialed and signed • Parent/guardian has initialed and signed • Witness has signed

Reviews request to make sure there is no clinical contraindication Releases information Authorization form and a copy of the response filed in the health record Health Information Tech maintains a log of all requests that contains: • Date and time request was received • Date and time request was reviewed by • Disposition of the request • Copy of Authorization form (also must be filed in health record) Documents a communication progress note that includes: • Name of person requesting the record & relationship to youth • If youth co‐signed the request • Purpose of the request, as stated on the Authorization form • What records were released? • If clinician was present when the records were reviewed by the Requestor