The Health Information Management department is dedicated to the effective management of patient information and healthcare data needed to deliver quality treatment and care to the public. The HIM professionals are responsible for the collection, storage, coding, processing, analysis, interpretations, application, privacy, and release of information.
Among the HIM department’s most important functions is that of filing and storing patient information. We, being a small facility, use an alphabetic patient identification and filing system. This filing system is divided into sections, surgery, observation, inpatient, outpatient and emergency room services. We are currently transitioning to Electronic Health Records to more efficiently manage records and better serve our community.
The Release of Information functions encompass protecting the security and privacy of information. Our department is responsible for determining appropriate access to, and release of information from, patient health records. ROI requires requests to be in written format, verification of the patient’s signature, and then only releases records; other requests, such as subpoenas are verified to be valid before information can be released. The HIM department is ultimately responsible for ensuring that proper practices are followed and that all laws and regulations are adhered to.
Our coders capture accurate and timely medical data; our medical coding professionals transform verbal descriptions of diseases, injuries, and procedures into numeric designation while considering the quality of the data or compliance to applicable federal and state rules and regulations. This accurately coded data from the medical record is used on claims for reimbursement, as well as being included on data sets to evaluate the processes and outcomes of healthcare provided.
The HIM Department ensures that every patient receives a proper and completed medical record. This stated, all required reports, either written or dictated, shall be completed by the attending physician within 30 days of the time of discharge. A discharge summary is required on all patients with the exception of those discharged in less than 48 hours; in this case, a short stay record may be used. We offer transcription services, which are out-sourced, with a 24-hour turn-around time. Dictations may be done by using a digital recorder, or via telephone.
The concepts of privacy, confidentiality, and security are central to our HIM department. Security ensures that the information stored in a health record is protected from unauthorized alteration, damage and loss. For more information on how our Medical Records/Health Information Management department functions, or to access a copy of your records, contact Britney Strickland, Director of Medical Records at 409.267.3143.
For your convenience, you may download the Release of Information Authorization form below and complete the form to expedite the process of getting a copy of your medical records. Please bring the completed form when and bring it with you.
Release of Information Authorization form