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Medical Records Health Information Management Manual

Medical Records Health Information Management Manual

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Medical Records Health Information Management Manual is a manual containing many of our policy and procedure templates for the medical office, hospital, and other healthcare organizations. The policies cover: Joint Commission (JCAHO or TJC) • CMS • HIPAA • CDC • AAAHC and more.
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Changes

Medical Records.7.changes Most current changes

Table of Contents - TJC, NIAHO standards Copyright Disclaimer Approval/Signature Sheet Introduction

SECTION 01 - EMERGENCY MANAGEMENT

Emergency Management Emergency Management Call-Back Tree Sample Emergency Management Responder List Disclosure of Protected Health Information During Disaster Relief Efforts Medical Records Security During Evacuation Procedures

SECTION 02 - ENVIRONMENT OF CARE

General Safety Information Report of Safety Hazard Form Body Mechanics - Staff Education Handout Electrical Safety Information Hazard Communication Program Hazardous Materials and Waste - Training Fire Safety - Health Information Management Types of Fire Extinguishers Health Information Management Department Fire Plan Equipment Supplies and Requisitions

SECTION 03 - HUMAN RESOURCES

Registered Health Information Administrator (RHIA)Staffing Position Description/Performance Evaluation - Health Information Management Department Director Annual Competency Skills Assessment - Health Information Management Department Director Position Description/Performance Evaluation - HIM Supervisor Annual Competency Skills Assessment - HIM Supervisor Position Description/Performance Evaluation - HIM Technician Annual Competency Skills Assessment - HIM Technician Position Description/Performance Evaluation - HIM Coder Annual Competency Skills Assessment - HIM Coder Position Description/Performance Evaluation - HIM Correspondence Clerk/Receptionist Annual Competency Skills Assessment - HIM Correspondence Clerk/Receptionist Position Description/Performance Evaluation - HIM Scanning Clerk Annual Competency Skills Assessment - HIM Scanning Clerk Position Description/Performance Evaluation - HIM Data Specialist Annual Competency Skills Assessment - HIM Data Specialist Position Description/Performance Evaluation - HIM Inpatient File Clerk Annual Competency Skills Assessment - HIM Inpatient File Clerk Position Description/Performance Evaluation - HIM Physician Assistant Clerk Annual Competency Skills Assessment - HIM Physician Assistant Clerk Position Description/Performance Evaluation - HIM Birth Certificate Clerk Annual Competency Skills Assessment - HIM Birth Certificate Clerk Position Description/Performance Evaluation - HIM Transcription Clerk Annual Competency Skills Assessment - HIM Transcription Clerk Position Description/Performance Evaluation - HIM Weekend Clerk Annual Competency Skills Assessment - HIM Weekend Clerk Position Description/Performance Evaluation - HIM (SNF) Clerk Annual Competency Skills Assessment - HIM (SNF) Clerk Annual Competency - Joint Commission National Patient Safety Goals and Universal Protocol Performance Standards and Evaluation - Medical Transcriptionist New Employee Orientation Orientation Checklist - Health Information Management Department Staff Staff Member Evaluations Personnel Action Form Inservices Departmental Inservice Record Form Attendance Absenteeism and Tardiness Attendance Counseling Form Excessive Tardiness Form Attendance Counseling Final Warning Form Coverage Schedule Coverage Schedule Form Department Meetings Phone Call Courtesy

SECTION 04 - INFECTION PREVENTION AND CONTROL

Hand Hygiene - CDC Guidelines Respiratory Hygiene/Cough Etiquette in Healthcare Settings Contamination of Medical Records by Blood/Body Fluids

SECTION 05 - INFORMATION MANAGEMENT

Purpose and Objectives Healthcare Confidentiality Principles Statement of Confidentiality Form - Staff Statement of Confidentiality Form - Contracted Individuals Data Protection and Confidentiality Guidelines for Departments Health Data Integrity Uses and Disclosures of Protected Health Information - General Rules Uses and Disclosures of Protected Health Information - Minimum Necessary and Incidental Disclosures Disclosure of Protected Health Information to Law Enforcement Without Individual Authorization Uses and Disclosures of Protected Health Information Subject to an Agreed-Upon Restriction Restriction Agreement - Release of Patient Protected Health Information Consent Form Accounting of Disclosures of Protected Health Information Violation of Confidentiality/Security of Organizational Information Administrative Safeguards - Sanctions Access and Maintenance of the Electronic Health Record Scanning Documents into the Electronic Health Record Retention of Medical Information Accessibility of the Medical Record Medical Record Request Medical Record Request Form Utilization of the Facsimile Machine Fax Transmittal Sheet Guidelines for Use of Electronic Mail Social Media Sites Removal of Records Correspondence Procedures Correspondence Log Patient Access to Medical Records Release of Medical Information Access to Copies of Your Medical Record Form Denial Letter for Direct Access to Medical Record - Sample Release of Patient Information Consent Form Medical Record Release Assessment List Release of Information When Consent is Not Required Request by Authorized State or County Department of Health Services Representatives for Access to Hospital Records or Other Documents for Licensure and Other Statutory Purposes Itemized Bill for Recovery of Reasonable Cost Staff Members Access to Their Own Electronic Medical Record Response to a Subpoena for Medical Records Response to Subpoena Duces Tecum Form Declaration of Custodian for Medical Records Form Contracted Photocopiers Statement of Confidentiality Form - Contracted Service Certificate of No Record Certificate of No Records Form Secure Filing of Medical Records Medical Records Destroyed by Man-Made or Natural Disaster Destroyed Medical Record Log Contingency Plan for Water Damaged Medical Records Computer Interruption/Malfunction/Destruction Plan Monitoring the Medical Record for Acceptable Abbreviations Documentation and the Use of Abbreviations, Acronyms and Symbols Unacceptable Abbreviation and Symbol List Signatures, Initials or Computer Key Identification Sample Wording for Signature Stamp Authentication Form Electronic Signature Authorization/Confidentiality Form Retrieval of Information/Disease and Operation Indices Code Sets Abstracting Coding of Medical Records Birth Registrar Hospital Statistics Statistical Formulas Statistical Report Form Monthly Statistical Report Form Census Reports Census Distribution Form Cardiac Arrest Data Sheet

SECTION 06 - LEADERSHIP

Health Information Management Department Organizational Chart Mission Statement Scope of Service Hours of Operation Communication to Physicians and Staff Ownership of Medical Records Sample Conditions of Admission to Hospital Form Electronic Health Records - Surveyor Access

SECTION 07 - PERFORMANCE IMPROVEMENT

Performance Improvement Plan Information Management Committee - Quality Review of the Medical Record Form Health Information Management PI Monitoring and Evaluation Plan Health Information Management PI Trending Sheet Health Information Management PI Outcome Evaluation Health Information Management PI Volume Measures/Statistics Health Information Management - Long Term Care PI Volume Measures/Statistics Health Information Management - Medical Staff PI Volume Measures/Statistics Advance Directives Deficiency Log Unplanned Return Transfer Sheet

SECTION 08 - RECORD OF CARE, TREATMENT AND SERVICES

Medical Record Content

Medical Record Content Policy Entries in the Medical Record Corrections to the Paper Medical Record Late Entries to the Electronic Health Record Addendum to the Electronic Health Record Amendment to the Electronic Health Record Legibility of Medical Record Documentation Medical Record Guideline for Physicians Admission Assessment Form Medication Reconciliation/Verification - Inpatient Medication Reconciliation/Verification - When Medications Medication Reconciliation/Verification Form Emergency Department Medical Record Emergency Department Nursing Assessment Form Medication Documentation Medication Administration Record Advance Directives Patient Self-Determination Act Checklist History and Physical Patient Consent for Treatment Authorization for Treatment Form Informed Consent Consent for Surgery - Minors Authorization for Third Party to Consent to Treatment of Minor Lacking Capacity to Consent Form Authorization for and Consent to Surgery or Special Diagnostic or Therapeutic Procedures Form Autorizacion y Consentimiento de Cirugia o Procedimientos Diagnosticos o Terapeuticos Especiales Forma Authorization and Consent - Recordings, Films or Other Images, and Publication Form Consent for Myelogram Form Consent for Intravenous Contrast Form MRI Consent Form Consent for Blood Test for HIV Antibody Form Disclosure of HIV Antibody Test Results Authorization for Disclosure of the Results of the HIV Antibody Blood Test (Sample Form)Blood/Blood Component Transfusion Consent Form Refusal to Permit Blood/Blood Component Transfusion Form Informed Consent for Angiogram Form Temporary Absence Release for Patients Temporary Absence Release Form Authorization for Autopsy Form Receipt for Body Death Summaries for Inpatient, Skilled Nursing and Emergency Department Medical Record AMA/Elopement from Facility Leaving Hospital Against Medical Advice Form Documentation Required for a Surgical Case Documentation of Operative and Other High-Risk Procedures Surgical Logbook Pre and Post Anesthesia Evaluation Form Anesthesia Record Form Post Anesthesia Care Unit Record Form Sedation Monitoring Form Intake Worksheet Documentation - Progress Notes Restraint/Seclusion Orders - Physician's Order Sheet Restraint and Seclusion Nursing Flowsheet 24-Hour Restraint Record Use of Summary List Sample Summary List - Ambulatory Care Services Verbal and Written Orders - General Telephone, Verbal and Written Orders for Medication Discharge Summary Patient Transfers - Documentation in the Medical Record Intrafacility Transfer Process Patient Transfer to Another Facility - Interfacility Skilled Units Patient Transfer Medical Records to be Sent with Patient Transfers Physician's Discharge Diagnosis and Order Record Patient Discharge Instructions Form Patient Transfer and Referral Record Form Signing of a Death Certificate

Medical Record Assembly and Maintenance

Patient Medical Record Unit Records Unit Record Form Medical Records for Skilled Level Residents Filing of Medical Records Filing System Color-Coding Medical Record Locator Medical Record Location Master List Chart Thinning Discharge Procedures Medical Record Audit Patient Deficiency Report Form Medical Records Filed as Incomplete Incomplete Medical Records Form (Physician as Attending)Incomplete Medical Records Form (Physician as Consultant)Delinquent Medical Records Delinquent Medical Records Sample Letter Physician's Notice of Delinquent Charts Form Notice of Upcoming Suspension for Incomplete Medical Records - Sample Letter Medical Staff Suspension List Physicians Suspension Log Phone Log - Physicians Off Suspension Medical Record Assembly Assembly Order of Emergency Department Medical Records Assembly Order of Medical Surgical Medical Records Assembly Order of Newborn Medical Records Assembly Order of Obstetrical Medical Records Assembly Order of Outpatient Autologous Blood Draw Assembly Order of Outpatient Surgery Medical Records Assembly Order of Pain Management Medical Records Assembly Order of SNF Medical Records Permanent Filing and Retention of the Medical Record Incomplete Record Filing Incomplete Medical Record Removal Medical Record Retention State Hospital Association Record Retention Recommendations Intentional Destruction of Medical Records Multiple Volume Medical Records Regulations for Off-Site Record Storage Off-Site Centralized Storage of Inactive Patient Records Record Receipt for Off-Site Storage - Sample Receipt and Agreement Expense Sheet for Off-Site Storage Delivery Charges - Sample Form State Department of Health Services Licensing and Certification - Program Flexibility Request Form Medical Record Review Function Medical Record Review Tool - Sample Form Medical Record Review - Point of Care Data Collection - Analysis Desk Analysis Worksheet Dictation Report Data Collection Performance Improvement Transfer Medical Records Data Collection Performance Improvement Admission Assessment - SNF Departments Performance Improvement Patient Self-Determination Act Data Collection Performance Improvement Conditions of Admission Data Collection Performance Improvement Physician Orders Audit - SNF Medical Records Performance Improvement Transcription Transcription Service: New Surgery Schedules, Add-on Surgeries, Changes in Surgery Schedule Contract Example for Transcription Service

SECTION 09 - RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL

Patient Rights and Responsibilities Confidentiality of Information - General Issues

SECTION 10 - ADDITIONAL SAMPLE FORMS

Sample Directives for Resuscitation Form Daily Care Record Sample Physician's Orders - Routine Bronchoscopy Procedure Sample Physician's Orders - Patient Controlled Analgesia (PCA)Sample Physician's Orders - Routine D&C Pre-Op Sample Physician's Orders - Pre-Delivery Sample Physician's Orders - Routine C-Section Pre-Op Sample Physician's Orders - Post-Cesarean Birth Sample Physician's Orders - Routine Postpartum Sample Physician's Orders - Routine Local Eye Procedures Sample Physician's Orders - Routine Orthopedic Pre-Op Sample CCU Order Sheet Lapses of Consciousness Form Surgical Checklist and Preoperative Nursing Record Outpatient Surgery Preoperative Nursing Assessment Form Advice and Acknowledgment of Child Passenger Safety Law Form