Medical Records Procedure Manual
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 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
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 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
References: Green, M. A., & Bowie, M. J. (2010). Essentials of Health Information Management: Principles and Practices. Retrieved from University of Phoenix University of California. (2008). Legal Medical Record Standards. Retrieved from http://www.ucop.edu/ucophome/coordrev/policy/legal-medical-record-policy.pdf