Assembling Charts

Properly assemble inpatient. Assembly of aesculapian records are done in * Chronological order according to filing order of the medical record. * create manakins according to the order given in this policy * Charts are identified with typewritten white labels with 1) longanimous Name 2) Electronic Health Record Number (MRN) put of Chart Assemble 1. Face sheet * Patient knowledge and Guarantor 2. Consent impresss * Signed Yearly Consent Form * Medicare Consent Forms * Counseling Form * BC Consent 3. Lab Reports Pathology Reports * Laboratory Reports 4. Prenatal (Only Pregnant Patients) 5. Hospital DC * All hospital discharges including ER visits 6. cardiac * Echocardiography results * 12-Lead EKGs * Stress Test Results * Cardiac catherization results * Venous & / or Arterial Duplex results * All other heart related 7. Procedures * Biopsy * Op reports (colonoscopy, cholecystectomy, CABG, etc) * All procedures * Home Health Orders 8. Correspondence * Letters from consulting phys icians 9. Medical recital (Old Records) 0. Miscellaneous I got to watch Mrs. Cathy as she reviewed charts for deficiencies. If any deficiencies are berthd a note is put on the chart and the chart is returned to the physician to soak up all documentation correct or signed. At 11 oclock we had a staff meeting where all the staff, even those that work from house keep abreasts in and we reviewed VEH growth, scores, and what the department needs to be doing in the up coming weeks. After lunch we started reviewing CDs that have been created from past musical theme charts.The paper charts have been put on CD to help conserve space, and create a more secure source for saving ad storing past medical histories. 1. X-Rays * All X-Rays * Mammogram * CT Scans, MRIs * Ultrasound * Nuclear Medicine test results * IVPs * DEXA scans * Thyroid scans 2. Referrals * All documentation for referral of patients to outside providers 3. Communication * Orange Telephone Message / economic consumption Sheets * Any Provider to patient communication including i. Letters of Missed appointments / no shows i. Letters of Patient Termination 4. HIPAA * Al Consents Treatment, Release of Information & Authorization 5. Patient Info / Billing * Patient demographics * CAP information * Insurance information including copies of insurance cards It is important that all documentation such as spell of the names, addresses of the parents, and full names of the parent are correct the final submitted document. It is a costly mistake for the parents to have to change this information later after submission.This is where HIPAA polices come into effect and help healthcare personal to maintain administrative, physical and technical safeguards in protect confidentiality and prevent unauthorized access to health information. It was interesting to perk that any if a mother is not married, and the father is not present when signing the application for a birth certificate that he must right to add his na me after the birth certificate has been filed with the NC Birth Certificate Registry. Ms. Boyd has 4 days to submit Birth and Death Certificates to the Edgecombe County Health DepartmentAfter numerous trips to swan that all the information was correct on the birth certificates, Ms. Boyd took the duration to go over all department policies and procedures for the Release of Information. It is the Health Informations superiors responsibility to make sure that private information is not release into the wrong hands. Failure to do so affects departments credibleness in performance and security of information. Guidelines for ROI Reviews the Authorization form to ensure Specific records are requested (general statements such as all mental health Information or all medical records are not HIPAA compliant) Clearly specific reason for the released record Expiration date Youth has initialed and signed Parent/guardian has initialed and signed Witness has signed Reviews request to make sure there is no clinical contraindication Releases information Authorization form and a copy of the solvent filed in the health record Health Information Tech maintains a log of all requests that contains Date and time request was received Date and time request was reviewed by Disposition of the request Copy of Authorization form (also must be filed in health record) Documents a communication progress note that includes Name of person requesting the record & relationship to youth If youth co? signed the request Purpose of the request, as stated on the Authorization form What records were released? If clinician was present when the records were reviewed by the Requestor