Beaufort-Jasper-Hampton Comprehensive Health Services, Inc.

Health Information Services Department

Policies and Procedure Manual

 Revised:  June 1, 2007

 Table of Content

I.                  Health Information Services Organizational Flow Chart

II.               Scope of Services

III.           Release of Information

a.     Authorization for Release of Information

b.     Authorization for Use and Disclosure of Information

c.      Authorization for Use and Disclosure of Information Via Telephone, Emergency, or In Person

d.     Faxing Medical Records

IV.           Medical Records

a.     Confidential Information in the Medical Record

b.     Chart Order

c.      New Medical Record

d.     Medical Record Volume

e.      Entries in Medical Record

f.       Changes to the Medical Record

g.     Ownership of Medical Record

h.     Protection and Availability of Medical Record

i.       Chart Analysis

j.       Secure Filing of Medical Records

k.     Chart Request and Chart Return

l.       Removal of Records

m.  Auditing of Misfiles

n.     Purging and Retention of Records

o.     Medical Record Retention

p.    Scanning Loose Material

q.     Document Imaging

V.               Patient Information

a.     Patient Registration

b.     Patient Complaint

c.      Visitor Log

VI.           Financial Information

a.     Proof of Income

b.     Coding

c.      Check Processing

d.     Missing Route Slips

e.      Petty Cash

VII.        Other

a.     Computer Failure/Patient Index

b.     General Safety Guidelines

c.      Cardiopulmonary Resuscitation (CPR)

 Health Information Services Organizational Flow Chart

 Scope of Services

Policy:

It is the policy of the Health Information Services Department to oversee the timely processing, completeness and retrieval of all patient medical records.  Health Information Services is provided to all areas of the facility as it relates to the individual’s need.  Our services include provision of an accurate patient electronic and paper chart, registration and collection for services rendered.

PROCEDURE:

Receptionist

·         Schedules and reschedules appointments for new and established patients.
·         Updates patient’s demographics each visit.
·         Identifies correct payer source.
·         Identifies correct facility type.
·         Identifies correct provider for visit.
·         Calculates patients sliding fee scale according to guidelines.
·         Verifies insurance coverage for rendered services.
·         Run encounter form for each face-to-face provider visit.
·         Pull paper charts for patient’s visit within 48 hours to assure information is scanned into the Practice Partner System.
·         Prepares loose material to be scanned.
·         Prepares written request for medical information within 2 business days.
·         Monitors waiting area to assure patients are compliant with agency guidelines regarding food and drink in the lobby, use of cell phones and general safety.
·         Assures all paper records and reports are located for patient care or review and secured at the close of the business day.
·         Assures the appropriate signatures are obtained on all reports before filing into the paper medical record.
·         Assures all paper medical records are refilled in the proper terminal digit order and are retired if applicable according to guidelines.

 Accounts Receivable

·         Updates patient’s demographics each visit.

·         Identifies correct payer source.

·         Identifies correct facility type.

·         Identifies correct provider for visit.

·         Calculates patients sliding fee scale according to guidelines.

·         Verifies insurance coverage for rendered services.

·         Daily completes collection sheet.

·         Reports cash shortage/overage. 

·         Assures petty cash balances. 

·         Resolves discrepancies with daily collection. 

·         Runs missing encounter report daily to assure duplications are corrected and missing charges are entered. 

·         Gives patients correct change during transactions.

Scan Clerk

·         Assist in locating the patient’s health information in EHR via the Practice Partner system or the paper chart. 

·         Assures all completed loose material is scanned into the EHR System or placed in the paper chart under the appropriate tab within 24 hours. 

·         Assures the appropriate signatures are obtained on all reports before scanning or filing into the patient’s Electronic Health Record.

Spanish Interpreter

·         Assist the nurse, pharmacist, dentist, physicians and HIS Staff with translation services related to patient care, registration or payment for services. 

·         Translates medical and dental documentations from English to Spanish. 

·         Assist staff in creating appointments for Hispanic population.

Release of Information Clerk

·         Process written requests for medical records within 2 business day. 

·         Assures the appropriate payment method is entered in the system by the Accounts Receivable Clerk. 

·         Daily updates the Release of Information Database. 

·         Calculates charges for the medical record request.

Central Scheduler

·         Assures patients are scheduled in accordance with agency guidelines. 

·         Assures patients demographics are updated. 

·         Assures all visitors are tracked when entering and leaving the center.
 

Release of Information

Policy

It is the policy of the Health Information Services Department to receive and process Authorization for Release of Information requests.  The original authorization form shall be scanned into the patient’s Electronic Health Record or placed in the hard copy medical record under the miscellaneous tab. 

Procedure

• Receptionist shall review all Authorization for Release of Information request for completeness using the following criteria:

1.      Requested Date of Service

2.      Requested Information

3.      Expiration Date

4.      Purpose of Disclosure

5.      Company Address and Contact Number

All incomplete request and request for the entire record and shall be forwarded to the HIS Supervisor for review.

• If applicable, receptionist shall pull the hard copy medical record and forward to the Release of Information Clerk along with the original request within twenty-four (24) hours.

Release of Information Clerk

• Verify that all requested documents are copied in accordance with the authorization.  All requests shall be recorded in the Release of Information Database for future reference.
• The total charges for the records shall be calculated and a submittal for payment shall be mailed or faxed to the requestor.  Once payment is received, the records shall be mailed within 2-3 business days via certified mail.
• Individuals that are present at the center and request copies of medical records must provide a valid picture ID and be ready to make a payment.
• Patient’s records will be forwarded free of charge to physicians providing continuing medical care for BJHCHS, Inc. patients.  All agencies, attorneys or individuals requesting copies of medical records will be charged a fee.

Record Fees

The following information shall be released after an Authorization for Release of Information has been signed and the established procedure has been followed:

·         Medical record information generated during primary care visits at any Beaufort-Jasper-Hampton Comprehensive Health Center. 

·         Medical record information shall be released to insurance companies for treatment, payment and healthcare operations. 

·         Psychiatric care records, documented sexual diseases, alcohol and/or drug, AIDS/HIV treatment or testing may be released if the appropriate section of the Authorization for Use and Disclosure of Information is signed by the patient. 

·         Copies of medical records for deceased HIV patients will only be released to personal representatives of the deceased appointed by the probate court. 

·         Copies of immunizations may be released to a school nurse or parent without a signed Authorization for Use and Disclosure of Information. 

·         Medical records pertaining to a Worker’s Compensation claim must be provided to the patient, insurance carrier, employer, attorney or the South Carolina Worker’s Compensation Commission within fourteen (14) days after receipt of written request.

Policy

It is the policy of the Health Information Services Department to treat all information contained in the patient’s medical record as confidential.  Unauthorized disclosures of any confidential information from a patient’s medical record by the Health Information Services Department will result in dismissal.  Requests for patient information will be directed to the appropriate individual in the Health Information Service Department.  The Health Information Service Department will release the minimum necessary of information in a patient’s charts.  All request for the entire record will be forwarded to the HIS Supervisor for approval.

Beaufort-Jasper-Hampton Comprehensive Health Services, Inc. will not disclose medical information regarding a patient without obtaining written authorization.  The authorization must come from the patient or patient’s representative.  If an authorization is signed by the patient, the medical record must reflect that the patient is competent to make a rational decision.  If the authorization is signed by a guardian or representative, he/she must submit evidence such as Power of Attorney, Court Order etc. that he/she has the power to authorize the release of medical information. 

Procedure

Beaufort-Jasper-Hampton Comprehensive Services, Inc. is required to release information without obtaining a patient’s written authorization to comply with the following:

§         Court Order

§         Administrative agency order

§         Subpoena Duces Team

Documents not subject to Subpoena Duces Team are psychiatric, alcohol abuse, drug abuse and AIDS related medical records.  Mental health records will require a special subpoena which must be a court ordered subpoena.  This subpoena means that the records will only be released to the court and not to a participating parties or attorneys.

§         Investigation Subpoena

§         Arbitration Order

§         Search Warrant issued by Judge

§         Laws that require release of medical information

A valid Authorization for Release of Information shall include the following:

§         Name of the institution/person that is to release information

§         Name of the institution/person that is to receive the information

§         Patient’s full name and identification number