Neighbors Caring For Neighbors!

^{ADMINISTRATION EMPLOYMENT} ^{SERVICES PHYSICAL THERAPY EMS HOME HEALTH CLINIC SURGERY AUXILIARY BILLING NURSING PHARMACY ACTIVE PHYSICIANS ADMISSIONS RECRUITING BOARD PRIVACY NOTICE}		HEALTH INFORMATION MANAGEMENT SERVICES
		HIMS, more commonly known as the Medical Records Department, houses patient records for all patients admitted or accepted for treatment to Ward Memorial Hospital. A unit record is kept in order to account for a complete medical history of the patient. The unit record is compiled of every encounter of a patient whether the encounter is an inpatient hospitalization, 23 hour observation stay, emergency room visit, or outpatient ancillary service, such as lab, x-ray, respiratory therapy, etc. The records are maintained for the benefit of the patient, the professional staff, and the hospital. Records are preserved in accordance to legal statues for a minimum of ten years with exception for newborn, pediatric and obstetric patients. However, the department has maintained some files in microfilm form for more years than the 10 years now required.
		The Medical Records staff responds to requests for copies of the records for personal use by the patient, for legal issues, for insurance issues, and for continuing health care. Confidentiality is at the forefront of the release of records. The Ward Memorial Medical Records staff has undergone training in the new HIPAA regulations and restrictions concerning confidentiality and release of protected health information to ensure patient confidentiality and HIPAA compliance. Records are not released without appropriate authorization by the patient. When requesting records, keep in mind that the completion, preparation, and copying the complete record are often time consuming due to multiple encounters over several years. State law allows the Medical Records Department 15 days to produce copies of records. The WMH Medical Records staff strives for efficiency but patients should allow adequate time when requesting records. Charts are monitored and audited for completion prior to filing by the Medical Record Staff. Incomplete records are not released except for continuing medical care.
		The Medical Records Department is involved in statistical reporting for hospital operations as well as reporting to state agencies such as Texas Cancer Registry, Bureau of Vital Statistics (Birth Certificate division), Texas Birth Defects Monitoring division, and Texas Office of the Attorney General Paternity Opportunity Program. The Medical Records Department maintains files of completed Advance Directives (Living Wills) and Durable Power of Attorney for Health Care (Medical Power of Attorney) forms for those patients who wish to express their desires for health care decisions and future treatment under adverse circumstances. Every encounter by a patient must be diagnosed and coded with an ICD-9 CM code to allow billing, statistical accounting, reporting, and tracking. The Medical Records department is responsible for abstracting data from the patient’s chart and entering data into the computer for billing purposes. Diagnosis and procedure codes are submitted by a coding firm of qualified professionals but ultimately audited by the Medical Records staff.
		Transcription of reports dictated by physicians is handled by an outside transcription firm. The transcribed reports are submitted electronically, printed by the Medical Records staff, and dispersed to appropriate charts, physicians, and departments.
		Patient Bill of Rights / Medicare Bill of Rights / HIPAA Information