G_line

HIM Dept.

Function

Goal

Tasks/Status

Electronic Document Management

· Standardize all Medical Record formats to 6 digit for MagicHealth EHR.

· Organize Electronic data from all sources for placement into

MagicHealth.

1) 6 digit all numeric format rolled out.

2) All sites up to date with 6 digit format for new appointments/patients.

3) Policy and procedure written and distributed to all sites. 4) Documentation Guidelines updated and distributed.

5) Education to all sites: review of policies/procedures/guidelines.

Coding

· Merge all coding under one manager.

· Incorporate Professional Fee [Profee] coding from acquired clinic locations.

1) Identify coders with Profee experience. Test and identify coders. 2) Select lead Profee coder.

3) Centralize coding in existing HIM department using old paper file room.

4) Modify room, order and place furniture and supplies. 5) Hire staff.

6) Write Profee coding procedures.

7) Update policies to include coding expansion.

Transcription

· Absorb transcription from acquired clinics into existing outsource

transcription volume.

1) Meet with Outsource Transcription Company. 2) Provide acquired clinic report examples.

3) Designate date for absorption of acquired clinic reports.

4) Roll out clinic transcription to outsource company

Release of Information

· Centralize all ROI at LiveWell.

· Merge ROI to have one overseeing manager.

· Observe ROI practices at each acquired clinic location. (Task completed - See Table 2 below)

 Write guidelines that include:

A. Prepare a step by step process for ROI between acquired clinics.

1. Communicating between Clinic locations on ROI requests

2. Logging /Tracking Requests

3. Tracking Types of Requests: patients, subpoenas, doctors, insurance, etc.

4. Distribution of Records to be released.

B. Considerations that might impact the guidelines: HIPAA Privacy, Security and Confidentiality, Mental Health and Alcohol/Drug Treatment Records, Disclosure Tracking - HIPAA

Name

Medical Record Format

MR#

Example

Specialty

ROI Observations Made by HIM Director

DurHealth

4 numeric digits

4578

Pediatric

Patient’s mother asks for a school physical report for the football coach at school. Office clerk gives mother a Release of Information form; mother fills it out with names and phone numbers. Clerk logs

the request and faxes the physical to the coach.

MorHealth

6 numeric digits

015896

Internal Medicine and Urgent Care

Patient asks for a two copies of her lab result – one for her adult daughter who is a nurse and another copy for her nephrologist. Office Manager prints a copy, tells patient to give it to her daughter. Patient is then sent to the ROI office to get the copy for her nephrologist. ROI office will

send copy directly to the nephrologist.

Dr. Behrens Office

3 alpha (1st three of last name, 4 numeric (month and year DOB)

Gar0161

Family Practice, Behavioral Health

Patient requests copy of record for her MD in Florida who she sees over the winter. Office Nurse opens EHR, prints summary documents from March of current year to October including the ER visit in July and the visit to MorHealth urgent care. Gives them to patient in an envelope for Florida

MD.

ForHealth

6 numeric

410255

Pediatric

Receives subpoena for records on a child abuse case, hands the subpoena to the doctor at

ForHealth. No further action is known.

RocHealth

6 numeric

885547

Family Practice

Patient asks for current visit and previous visit to ER to be copied and sent to orthopedic surgeon out-of-town. She also asks for her son’s immunization record for the school he goes to now. Office scheduler prints it all and faxes it to

both locations.