ETHICS IN RESEARCH AND HEALTHCARE STATISTICS

ICP1: Ethics in Research and Healthcare Statistics Felder Post-Implementation Assessment

Felder Post-Implementation Assessment

EHR Release of Information Log Records are requested in the department using a form or by logging on to the patient portal. All records are sent via encrypted email,

automatically faxed, or prepared for patient pick up.

Release of Information Log- Electronic Health Record

Release of Information Approvals Request Date: (Insert date) Approval: (Approved/Pending) Date Filled: (Insert Date) Approver ID: (Insert staff ID) Patient Name: (insert patient name) Status: (Insert Status)

Request Date Date Filled

Item Type Patient Name Approver Status Completion Method

Actions/Notes

3/24/17 History & Physical Moore, Mary Ellen HIM Mgr. Pending 4/2/17 4/4/17 Complete Record Henry, Mark Aaron HIM Supv. Completed Fax No further action required

4/8/17 Complete Record Jones, Sue Ann ROI Mgr. Pending Incomplete record

4/9/17 4/9/17 Operative Report Parker, Lottie Mae HIM Mgr. Completed Email No further action required

4/20/17 5/18/17 Complete Record Douglas, Henry Allen HIM Supv. Completed Print/Pickup No further action required

ICP1: Ethics in Research and Healthcare Statistics Felder Post-Implementation Assessment

Release of Information Manual Release of Information Log Records are requested in the department using a form. All records are copied and mailed, faxed, or prepared for patient pick up. Hospital time

frame is within 30 days of request

Felder Community Hospital

Release of Information Request Log

Patient Name Date of Birth

Social Security Number

Medical Record Number

Date Requested

Date Filled Method

Mary Ellen Smith 2/16/45 xxx-xx-1453 365874 9/22/16 10/1/16 Mailed

James Quincy Robert 1/8/65 xxx-xx-5623 523845 1/4/17 2/12/17 Faxed

Carl Tyrone Biggs 7/12/75 xxx-xx-9696 745854 1/6/17 1/20/17 Mailed Janice Elaine Moore 6/19/57 xxx-xx-6587 125487 2/1/17 3/20/17 Mailed

Crystal Lynn Mayfair 1/4/82 xxx-xx-6258 458256 2/12/17 2/14/17 Mailed

Cynthia Marie Jones 6/4/76 xxx-xx-5241 749652 3/1/17 3/17/17 Faxed John Earl Wright 4/4/84 xxx-xx-9874 635241 3/1/17 4/2/17 Pt. Pick Up

Henry Allen Moore 8/12/46 xxx-xx-1489 748741 3/6/17

Connie Ann Lee 7/4/76 xxx-xx-4151 366587 4/1/17 4/6/17 Mailed

ICP1: Ethics in Research and Healthcare Statistics Felder Post-Implementation Assessment

Coding Life Cycle: Paper Records

The patient is discharged from the unit. The chart goes to chart completion. Flags are placed in the chart and doctors are notified of their

deficiencies. Once the chart is completed, the flags are removed from completed charts and the charts are added to the red coding cart.

These charts are ready for coding. Coders pick up charts for manual completion starting with the oldest. Coders begin working on charts.

There is a 72-hour turnaround time for charts with no deficiencies. Charts with queries are placed in the yellow query cart. Completed charts

are placed in the green completed coding cart with the coding abstract form attached. They are ready to be filed.

Coding Life Cycle: Electronic Health Records

The patient is discharged from the unit. The record is made available in the Electronic Health Record. The chart goes to the Deficiency

Analysis work queue. Charts with missing documentation used for coding are flagged electronically and sent to the physician. Charts that

have no deficiencies are then added to the coding work queue and made available for coders. There is a 48-hour turnaround time on

electronic charts. Coders complete coding using the integrated encoder. Once all codes are added, they click “submit” and the chart is

completed.