Medical Records

The Medical Records Department is open from 7:00 a.m. to 5:00 p.m. Monday through Friday except on holidays.

Responsibilities

The Medical Records Department is responsible for overseeing the timely processing, completeness, and retrieval of all patient medical records. A medical record is maintained on every patient treated at the facility and medical record services are provided to all areas of the facility. Medical record services include provision of an accurate patient record with emphasis on the following:

Record processing
Record abstracting, analysis, and coding
Transcription of appropriate reports for the medical records
Correspondence
Record retrieval, filing, and storage
Tumor registry
Birth certificates
Performance Improvement

Observation of patient needs and changes in legal and regulatory requirements are used to identify services to be provided and changes to be made to existing services.

Release of Information:Federal regulations, state laws, and AHIMA guidelines are used to determine compliance when responding to requests.

Birth Certificates: State law regarding completion and filing of birth certificates are used to determine compliance when registering birth information.

Transcription: Federal regulations, state laws, AAMT guidelines, and physician requests are used to determine transcription services.

Tumor Registry: State law for reporting cancer cases is used to determine compliance. In addition, requests by the Tumor Board influence other registry services.

Coding and Abstracting: Federal regulations, state laws, and AHA guidelines are used to determine compliance.

Performance Improvement: CMS and state programs are followed when possible along with the specific hospital driven program to determine the quality of services rendered.