Assembling Charts

Properly assemble in long-suffering. Assembly of medical records ar done in * Chronological fiat according to filing order of the medical record. * Assemble forms according to the order given in this constitution * Charts are identified with typewritten white labels with 1) Patient Name 2) Electronic health Record Number (MRN) Order of Chart Assemble 1. Face canvass * Patient Information and Guarantor 2. respond Forms * Signed Yearly Consent Form * Medicare Consent Forms * Counseling Form * BC Consent 3. science lab Reports Pathology Reports * Laboratory Reports 4. Prenatal (Only Pregnant Patients) 5. Hospital DC * in all infirmary 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 (colonostranscript, cholecystectomy, CABG, etc) * All procedures * Home Health Orders 8. Correspondence * Let ters from consulting physicians 9. Medical History (Old Records) 0. unhomogeneous I got to watch Mrs. Cathy as she reviewed charts for deficiencies. If any deficiencies are noned a note is put on the chart and the chart is returned to the physician to project all documentation correct or signed. At 11 oclock we had a staff meeting where all the staff, even those that work from home passs 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 away paper charts.The paper charts have been put on CD to military service conserve space, and create a more secure source for salve ad storing past medical histories. 1. X-Rays * All X-Rays * Mammogram * CT Scans, MRIs * Ultrasound * thermonuclear Medicine test results * IVPs * DEXA scans * Thyroid scans 2. Referrals * All documentation for referral of patients to outside providers 3. confabulation * Orange Telephone Mes sage / Intake Sheets * Any Provider to patient communication including i. Letters of Missed appointments / no shows i. Letters of Patient end point 4. HIPAA * Al Consents Treatment, relinquish of Information & Authorization 5. Patient Info / armorial bearing * Patient demographics * CAP information * Insurance information including copies of insurance card It is important that all documentation such as spelling of the names, addresses of the parents, and spacious 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 proficient safeguards in protect confidentiality and prevent unauthorized access to health information. It was interest to learn that any if a mother is not married, and the father is not present when signing the application for a birth authentica tion that he must pay to add his name after the birth certificate has been filed with the NC Birth Certificate Registry. Ms. Boyd has 4 days to submit Birth and demise Certificates to the Edgecombe County Health DepartmentAfter numerous trips to verify that all the information was correct on the birth certificates, Ms. Boyd took the time to go over all department policies and procedures for the Release of Information. It is the Health Informations professionals responsibility to reserve sure that private information is not release into the wrong hands. hardship to do so affects departments credibility in performance and security of information. Guidelines for ROI Reviews the Authorization form to ensure Specific records are pass along (general statements such as all mental health Information or all medical records are not HIPAA compliant) Clearly specific causation for the released record Expiration date Youth has initialed and signed Parent/ shielder has initialed and sign ed Witness has signed Reviews request to make sure thither is no clinical contraindication Releases information Authorization form and a copy of the response filed in the health record Health Information technical school maintains a log of all requests that contains Date and time request was standard Date and time request was reviewed by Disposition of the request repeat of Authorization form (also must be filed in health record) Documents a communication progress note that includes Name of person requesting the record & kind 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