Medical Records Services
Medical Record Services is a support service whose primary purpose is to contribute to the quality of patient care through the development and maintenance of a comprehensive centralized Medical Record system.
Services and functions shall be developed and implemented in such a way that confidentiality, privacy and data security considerations are respected at all stages of the health care information gathering and processing.
The system shall also provide Health Information to support and promote the related goals and activities of the health care facility in the areas of: education, training, research, facility management and decision-making.
Scope of Services
The centralized Medical Record Services shall provide functional support to the health care facility with respect to health information services to include:
Patient identification and numbering system.
Monitoring of clinical record documentation.
Digital dictation / transcription system.
Statistical abstracts / indexes.
Diagnosis and procedure coding utilizing ICD 9CM.
Special studies for medical staff committees and clinical departments.
Storage and retrieval system, including record tracking.
Assistance in complying with legal and regulatory provisions and accrediting agency standards concerning health care data.
Data security, privacy and confidentiality processes.
Educational programs for students under affiliation agreements.
Principle functions are provided by the following departmental sections:
Pull and file clinical records for direct patient care, Research & Study, Committees
Transcribe Discharge Summaries, Operative Reports, Medical Evaluations / Reports
Clinical Coding & Statistics, Record Assembly, Records Analysis, and Incomplete Record Completion
Achievements:
Installation of the new dictation system that offers load-sharing capabilities between the regions.
Continue to recruit staff for File Management, Data Management and Medical Transcription.
Assembly and analysis of long stay cases to ensure that reports are pre-assembled in advance to avoid loss and the admission is analyzed to ensure that Operative Reports are dictated before the patient is discharged, which could be years later.