I. ORIENTATION TO GENERAL HOSPITAL FUNCTIONS
Purpose: This assignment will assist the student in understanding the general functions
and services provided by the health care facility, the specific functions of the health
information department, and relationships between the health information department
and ancillary departments. Visit the site’s web site and interview your PPE supervisor or
designee to answer each item below.
Facility Information
Name and address of institution Memorial Hospital of Union County
Type of hospital Community hospital
Number of physicians on staff more than 150 physicians
Is there a residency program? no
Names of accrediting agencies ISO 9001:2008 certification, DNV
Descriptive statistics
Number of beds (including bassinets) 118
Average length of stay for adults and children, including newborns 2.56
Services Provided
List the services provided by the hospital, other than inpatient, outpatient and ED care
(e.g., home health, hospice, and so on).
Long-term care facility, short term rehabilitation, skilled, intermediate, and dementia care,
laboratory and
imaging services, occupational health center.
Health Information Department
Health information director name and credentials Gina Smalley- Interim Director RHIT
How many in the department are credentialed? 3 of the 5
What credentials do employees hold? RMC, RHIT
How many are employed by the health information department? 5
Is the department open nights and/or weekends? If so, how many employees work and
what are their major functions? No hours are 7-4:30, there is someone on call for
weekends.
Review policies and procedures for the health information department, and comment on
specific areas of interest. What are current issues the department is concentrating on for
policies and procedures? Cut, copy, paste procedures and copy forward issue on
progress notes and nurse’s notes
Patient Registration/Pre-Registration (Patient Admissions)
Describe the facility’s pre-registration process. What percent of the patients are
pre-registered?
Prior to actual procedure a paper is received by admission and they reach out to the
patient or sometimes the patient calls and get registered. They trey to get all patients preregistered before admission.
1.
2.
Review forms used during the pre-registration process, and describe the
information provided to the patient on admission (e.g., patient bill of rights, etc.).
Notice of the Health Information Privacy Practices, financial agreement….
Confidentiality, opt in opt out for HIPAA privacy, whether they can let anyone know they
are at the facility, living will information.
3.
List the consents that are signed by the patient during the admissions process.
Consent of treatment, Advance directive, Consent for anesthesia
4.
Describe the procedure involved in the admission of a patient.
All electronic
5.
Describe the relationship of the Admissions Department with the health information
department and the billing office.
Admission and billing under the same director. HIM does not have contact with the
admissions department very often. There is a constant communication with the business
office. There is communication about failed claims that are received in a Que.
The current HIM inpatient coder worked in the business office prior which has helped the
HIM department tremendously since she has the business experience.
6.
Review the process of assigning the patient number on admission. Which
numbering system is used? What relationship does this number have to the patient
number used by the health information department? Are they the same?
Straight numeric numbering system, terminal-digit filing system, middle-digit filing system
Uses account number more, which is different for each encounter, this is the main
identifier used in HIM, they call it the account number
Medical record number will always be the same
Billing Office
1.
Describe the relationship between the Billing Office and the heath information
department.
2.
Describe the completion of the UB-04 form and integration with data submitted to
the state department of health (e.g., SPARCS in New York State). What is the
name of the position responsible for inputting information that results in generation
of the data? What is the name for the position responsible for submitting this data
to the state department of health?
Business office, all do there own, job title is billing representative
II.
MEDICAL STAFF AND HOSPITAL COMMITTEE FUNCTIONS
Purpose: This assignment will permit the student to determine which medical staff and
hospital committees have representation by the health information department.
Interview your PPE supervisor or designee to answer each item below.
Name of Committee #1: utilization review
Membership him director, risk manager, case manager, director of quality
Preparation of records (pulling, etc) not done
What type of information is discussed? If they feel there is something that needs looked
at after discussion then they would do an audit
Who takes minutes? Case manager
Name of Committee #2: safety committee
Membership all directors
Preparation of records (pulling, etc) no chart auditing
What type of information is discussed? Talk about issues, brainstorm
Who takes minutes? Administrative assistant
Name of Committee #3: medical staff quality committee
Membership physicians, medical records director, risk managers
Preparation of records (pulling, etc)
What type of information is discussed? Physicians bring an issue, then an audit is
performed.
Who takes minutes? Administrative assistant
Name of Committee #4: compliance committee- meets quarterly
Membership gina, risk manager, quality director, IT
Preparation of records (pulling, etc) case mangers track trends
What type of information is discussed?
happens next
Who takes minutes? Quality director
Review of the trends and brainstorm what
III.
PATIENT RECORD STORAGE AND RETRIEVAL
Purpose: This assignment will familiarize the student with how patient records are
stored and retrieved. Interview your PPE supervisor or designee to answer each item
below.
1.
Review and describe the procedure for storage and retrieval of patient records.
Begin with the discharge of the patient and end with the record being filed in
permanent storage. If your facility has implemented an electronic health record,
include a description of this form of record maintenance as it relates to the storage
and retrieval of patient records.
Hybrid, inactive records in boxes HIM staff goes and retrieves at the hospital location, the
records are stored in fire proof boxes.
There are also 50,00 boxes of medical records not accessed very often at a off location
where they have staff there who retrieves the record and brings the record to the
hospital..
2. Describe how each of the following are maintained:
Master patient index - electronically
Physician incomplete files - electronic
Permanent files - electronic
3. Describe the patient record charge-out procedure, including the use of a
computerized chart tracking system?
Charges are put on by the specific unit, the money attached to the charge code pulled
from the charge master, which is then sent to the business office, coders then are putting
on codes, modifiers, and device codes.
4. Describe the record retention policy for the State and that which is hospital policy.
Hospitals coincide with state of Ohio, the current policy is out of date and is in the process
of being reviewed.
5. What filing system is used to store records?
Alphabetical
6. Describe the storage system is used for permanent filing (e.g., open shelves, lateral
files, movable shelving, electronic health record)?
7. How is the filing of "loose" reports handled?
Ex: EKG, there is a box where one of the indexers organizes and then gives to a scanner
who will enter into the electronic database..
8. Perform a database inquiry for special reports or resources, and describe the
results.
9. Retrieve data from a database (i.e., physician, disease index), and describe the
results.
Linked to 3m PDI, coding clinic on desktop
Emergency Department (ED) Records
1.
Where are ED records filed?
Electronically
2.
Do ED records become a part of the inpatient record if a patient is admitted to the
hospital from the ED?
Yes
3.
Is a patient register maintained for ED visits?
Yes
4.
Describe the information maintained in the ED register.
Name, address, DOB, SS#, next of kin, who to notify, living will, phone number, attending
physician
5. Approximately how many patients does the ED treat in an average day?
1683 per month
Medical Transcription
1. Review established procedures for medical transcription. Is medical transcription
performed at the hospital, or is it outsourced.
Remote from employees home but they are employees of the hospital
2.
Describe how and where physicians access the dictation equipment. What dictation
system is used?
MModal, they are currently in the process of getting an internal voice recognition
system by the name “afinity.”
3. Is medical transcription productivity and quality monitored? How?
Yes by the lead
4. What controls are used to determine the status of dictated reports?.
Monitored through the MModal system
5. If an outside transcription service is used, describe the procedure for sending and
receiving the material. Discuss any benefits or problems with using a service.
n/a
Microfilming/Microfiche
NOTE: If microfilming is done, complete the following items.
1.
Describe departmental procedures for preparing records to be microfilmed, the
procedure for microfilming records and disposing of microfilmed records
n/a
2. Describe the types of material/data that are kept in microfilmed version and the
available equipment.
n/a
IV.
DISCHARGED PATIENT RECORD PROCEDURES
Purpose: This assignment will familiarize the student with the processing of discharged
patient records. Interview your PPE supervisor or designee to answer each item below.
1.
Describe the steps in the assembly and analysis section of the health information
department. Begin with the discharge of the patient, and end with the chart placed
in permanent storage.
One of the HIM employees will retrieved the paper record, it will then go through index
scan quality check, once in the EHR it will go through another quality control, then goes to
assembly to check correct order and patient signatures, physician then completes, then
goes to coding, once complete it becomes a part of the permanent storage.
2.
Explain the discharged patient record analysis procedure completed in the health
information department.
3. Are ED and outpatient records reviewed for deficiencies when returned to the
department? Explain that analysis procedure.
Yes, same process as inpatient, coder will check for medically necessity, then goes to
billing office, last step is through a scrubber to make sure it will be paid.
4. How is the patient's current record coordinated with previous admissions?
Within the EHR
By date order
5.
Describe the hospital’s physician suspension policy for the hospital. Be sure to
describe the role of the health information department and hospital administration in
this process.
Chief of staff was expected to due this but did not and that is why Gina is now the interim
director. She is in the processing of reviewing all the old stuff.
6. Which job title is responsible for the delinquent chart count procedure?
Image coordinator
7.
What procedure is performed if a record is needed for an inpatient admission
before the entire discharged patient record process is completed (e.g., patient is
readmitted as an inpatient)?
Send them what is complete, history and physical usually complete, any labs, progress
note, do not send discharge summary if it is not completed.
V.
HOSPITAL STATISTICS
Purpose: This assignment will familiarize the student with the compilation and analysis
of health information statistics. Interview your PPE supervisor or designee to answer
each item below.
1.
Describe how the health information department is involved with gathering hospital
statistics (e.g., what data is gathered).
Very involved, monthly report, different departments send their stats to her and she then
compiles all the information.
Data includes, admission, discharge, and percent of occupancy, average length of stay,
observation days, treatment room patients, surgery counts.
2.
What job title is responsible for generating statistical data? What job title from the
health information department involved with this process?
Gina, the current interim director.
3.
Describe the statistical reports generated by the health information department.
Same as described in question 1.
4.
What statistical reports are used by the health information department? How?
Code of productivity reports, death report, admissions, discharge, discharge day report,
daily report of AR
5.
Review the procedure for completion of birth and death certificates, and describe
the process in detail.
Not sure, OB does the application and then generated at health department, death is
generated by unit where death occurred, signed by whoever pronounced the patient and
then sent to funeral home.
6.
What job title is responsible for the completing birth and/or death certificates?
Describe the procedure performed. Describe state requirements regarding the
submission of data.
Most likely the charge nurse.
VI.
RELEASE OF PATIENT INFORMATION
Purpose: This assignment will familiarize the student with policies and procedures
regarding the release of patient information. Interview your PPE supervisor or designee
to answer each item below.
1.
Review and describe the departmental policy and procedure for release of
information.
Patients request, signs a release, show id, department runs the copies and gives them to
the patient.
Hospital Transfers- no release needed
lawyers- goes to risk management, make sure its not a legal case against the hospital,
then released as long as the patient signed a release, lawyers are charged for the copies.
For court- If it is signed by the judge they will send the record,if not signed then someone
has to go until it is signed by the judge.
2.
Explain how each of the following requests are handled.
Physician – if actively involved then no consent needed, if not actively involved the
department will call patient and have them sign release,
insurance company- without
authorization
Another health care facility
– yes, authorization
needed.
Workers’ compensation –
require authorization,
unless there is open
evidence of an BWC claim
3.
How is release of information for each of the cases below handled?
Drug and alcohol abuse patientsAuthorization, unless open
criminal case proved by police
AIDS cases –
Authorization
Patient access to their own records authorization for documentation of
to have documentation of access
Mental health records –
authorization needed
4.
Describe the procedure for handling telephone requests for information. What
information, if any, may be released over the phone?
No information over the phone, have them complete an authorization
5.
Describe how in-hospital reviews of records are handled by outside agencies
handled.
Either let them come in and set them at a computer, or send to them in an
encrypted email or hard copy.