Medical Records Health Information Management Manual

MCN has created an all-inclusive manual covering everything you need in your Medical Records/HIM Department. With over 285 ready-to-customize policies, procedures and forms that meet the latest Joint Commission and NIAHO standards and CMS regulations, you won't have to worry about compliance. This comprehensive manual demonstrates best practices for the management of patient information and is completely cross-referenced to the latest TJC and NIAHO standards.

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Table of Contents - TJC, NIAHO standardsCopyrightDisclaimerApproval/Signature SheetIntroduction
SECTION 03 - HUMAN RESOURCES
3001 - Registered Health Information Administrator (RHIA)3002 - Staffing3003 - Position Description/Performance Evaluation - Health Information Management Department Director3004 - Annual Competency Skills Assessment - Health Information Management Department Director3005 - Position Description/Performance Evaluation - HIM Supervisor3006 - Annual Competency Skills Assessment - HIM Supervisor3007 - Position Description/Performance Evaluation - HIM Technician3008 - Annual Competency Skills Assessment - HIM Technician3009 - Position Description/Performance Evaluation - HIM Coder3010 - Annual Competency Skills Assessment - HIM Coder3011 - Position Description/Performance Evaluation - HIM Correspondence Clerk/Receptionist3012 - Annual Competency Skills Assessment - HIM Correspondence Clerk/Receptionist3013 - Position Description/Performance Evaluation - HIM Scanning Clerk3014 - Annual Competency Skills Assessment - HIM Scanning Clerk3015 - Position Description/Performance Evaluation - HIM Data Specialist3016 - Annual Competency Skills Assessment - HIM Data Specialist3017 - Position Description/Performance Evaluation - HIM Inpatient File Clerk3018 - Annual Competency Skills Assessment - HIM Inpatient File Clerk3019 - Position Description/Performance Evaluation - HIM Physician Assistant Clerk3020 - Annual Competency Skills Assessment - HIM Physician Assistant Clerk3021 - Position Description/Performance Evaluation - HIM Birth Certificate Clerk3022 - Annual Competency Skills Assessment - HIM Birth Certificate Clerk3023 - Position Description/Performance Evaluation - HIM Transcription Clerk3024 - Annual Competency Skills Assessment - HIM Transcription Clerk3025 - Position Description/Performance Evaluation - HIM Weekend Clerk3026 - Annual Competency Skills Assessment - HIM Weekend Clerk3027 - Position Description/Performance Evaluation - HIM (SNF) Clerk3028 - Annual Competency Skills Assessment - HIM (SNF) Clerk3029 - Annual Competency - Joint Commission National Patient Safety Goals and Universal Protocol3030 - Performance Standards and Evaluation - Medical Transcriptionist3031 - New Employee Orientation3032 - Orientation Checklist - Health Information Management Department Staff3033 - Staff Member Evaluations3034 - Personnel Action Form3035 - Inservices3036 - Departmental Inservice Record Form3037 - Attendance3038 - Absenteeism and Tardiness3039 - Attendance Counseling Form3040 - Excessive Tardiness Form3041 - Attendance Counseling Final Warning Form3042 - Coverage Schedule3043 - Coverage Schedule Form3044 - Department Meetings3045 - Phone Call Courtesy
SECTION 05 - INFORMATION MANAGEMENT
5001 - Purpose and Objectives5002 - Healthcare Confidentiality Principles5003 - Statement of Confidentiality Form - Staff5004 - Statement of Confidentiality Form - Contracted Individuals5005 - Data Protection and Confidentiality Guidelines for Departments5006 - Health Data Integrity5007 - Uses and Disclosures of Protected Health Information - General Rules5008 - Uses and Disclosures of Protected Health Information - Minimum Necessary and Incidental Disclosures5009 - Disclosure of Protected Health Information to Law Enforcement Without Individual Authorization5010 - Uses and Disclosures of Protected Health Information Subject to an Agreed-Upon Restriction5011 - Restriction Agreement - Release of Patient Protected Health Information Consent Form5012 - Accounting of Disclosures of Protected Health Information5013 - Violation of Confidentiality/Security of Organizational Information5014 - Administrative Safeguards - Sanctions5015 - Access and Maintenance of the Electronic Health Record5016 - Scanning Documents into the Electronic Health Record5017 - Retention of Medical Information5018 - Accessibility of the Medical Record5019 - Medical Record Request5020 - Medical Record Request Form5021 - Utilization of the Facsimile Machine5022 - Fax Transmittal Sheet5023 - Guidelines for Use of Electronic Mail5024 - Social Media Sites5025 - Removal of Records5026 - Correspondence Procedures5027 - Correspondence Log5028 - Patient Access to Medical Records5029 - Release of Medical Information5030 - Access to Copies of Your Medical Record Form5031 - Denial Letter for Direct Access to Medical Record - Sample5032 - Release of Patient Information Consent Form5033 - Medical Record Release Assessment List5034 - Release of Information When Consent is Not Required5035 - Request by Authorized State or County Department of Health Services Representatives for Access to Hospital Records or Other Documents for Licensure and Other Statutory Purposes5036 - Itemized Bill for Recovery of Reasonable Cost 5037 - Staff Members Access to Their Own Electronic Medical Record5038 - Response to a Subpoena for Medical Records5039 - Response to Subpoena Duces Tecum Form5040 - Declaration of Custodian for Medical Records Form5041 - Contracted Photocopiers5042 - Statement of Confidentiality Form - Contracted Service5043 - Certificate of No Record5044 - Certificate of No Records Form5045 - Secure Filing of Medical Records5046 - Medical Records Destroyed by Man-Made or Natural Disaster5047 - Destroyed Medical Record Log5048 - Contingency Plan for Water Damaged Medical Records5049 - Computer Interruption/Malfunction/Destruction Plan5050 - Monitoring the Medical Record for Acceptable Abbreviations5051 - Documentation and the Use of Abbreviations, Acronyms and Symbols5052 - Unacceptable Abbreviation and Symbol List5053 - Signatures, Initials or Computer Key Identification5054 - Sample Wording for Signature Stamp Authentication Form5055 - Electronic Signature Authorization/Confidentiality Form5056 - Retrieval of Information/Disease and Operation Indices5057 - Code Sets5058 - Abstracting5059 - Coding of Medical Records5060 - Birth Registrar5061 - Hospital Statistics5062 - Statistical Formulas5063 - Statistical Report Form5064 - Monthly Statistical Report Form5065 - Census Reports5066 - Census Distribution Form5067 - Cardiac Arrest Data Sheet
SECTION 08 - RECORD OF CARE, TREATMENT AND SERVICES
Medical Record Content
8001 - Medical Record Content Policy8002 - Entries in the Medical Record8003 - Corrections to the Paper Medical Record8004 - Late Entries to the Electronic Health Record8005 - Addendum to the Electronic Health Record8006 - Amendment to the Electronic Health Record8007 - Legibility of Medical Record Documentation8008 - Medical Record Guideline for Physicians8009 - Admission Assessment Form8010 - Medication Reconciliation/Verification - Inpatient8011 - Medication Reconciliation/Verification - When Medications Are Used Minimally8012 - Medication Reconciliation/Verification Form8013 - Emergency Department Medical Record8014 - Emergency Department Nursing Assessment Form8015 - Medication Documentation8016 - Medication Administration Record8017 - Advance Directives8018 - Patient Self-Determination Act Checklist8019 - History and Physical8020 - Patient Consent for Treatment8021 - Authorization for Treatment Form8022 - Informed Consent8023 - Consent for Surgery - Minors8024 - Authorization for Third Party to Consent to Treatment of Minor Lacking Capacity to Consent Form8025 - Authorization for and Consent to Surgery or Special Diagnostic or Therapeutic Procedures Form8026 - Autorizacion y Consentimiento de Cirugia o Procedimientos Diagnosticos o Terapeuticos Especiales Forma8027 - Authorization and Consent - Recordings, Films or Other Images, and Publication Form8028 - Consent for Myelogram Form8029 - Consent for Intravenous Contrast Form8030 - MRI Consent Form8031 - Consent for Blood Test for HIV Antibody Form8032 - Disclosure of HIV Antibody Test Results8033 - Authorization for Disclosure of the Results of the HIV Antibody Blood Test (Sample Form)8034 - Blood/Blood Component Transfusion Consent Form8035 - Refusal to Permit Blood/Blood Component Transfusion Form8036 - Informed Consent for Angiogram Form8037 - Temporary Absence Release for Patients8038 - Temporary Absence Release Form8039 - Authorization for Autopsy Form8040 - Receipt for Body8041 - Death Summaries for Inpatient, Skilled Nursing and Emergency Department Medical Record8042 - AMA/Elopement from Facility8043 - Leaving Hospital Against Medical Advice Form8044 - Documentation Required for a Surgical Case8045 - Documentation of Operative and Other High-Risk Procedures8046 - Surgical Logbook8047 - Pre and Post Anesthesia Evaluation Form8048 - Anesthesia Record Form8049 - Post Anesthesia Care Unit Record Form8050 - Sedation Monitoring Form8051 - Intake Worksheet8052 - Documentation - Progress Notes8053 - Restraint/Seclusion Orders - Physician's Order Sheet8054 - Restraint and Seclusion Nursing Flowsheet8055 - 24-Hour Restraint Record8056 - Use of Summary List8057 - Sample Summary List - Ambulatory Care Services8058 - Verbal and Written Orders - General8059 - Telephone, Verbal and Written Orders for Medication8060 - Discharge Summary8061 - Patient Transfers - Documentation in the Medical Record8062 - Intrafacility Transfer Process8063 - Patient Transfer to Another Facility - Interfacility8064 - Skilled Units Patient Transfer8065 - Medical Records to be Sent with Patient Transfers8066 - Physician's Discharge Diagnosis and Order Record8067 - Patient Discharge Instructions Form8068 - Patient Transfer and Referral Record Form8069 - Signing of a Death Certificate
Medical Record Assembly and Maintenance
8101 - Patient Medical Record8102 - Unit Records8103 - Unit Record Form8104 - Medical Records for Skilled Level Residents8105 - Filing of Medical Records8106 - Filing System8107 - Color-Coding8108 - Medical Record Locator8109 - Medical Record Location Master List8110 - Chart Thinning8111 - Discharge Procedures8112 - Medical Record Audit8113 - Patient Deficiency Report Form8114 - Medical Records Filed as Incomplete8115 - Incomplete Medical Records Form (Physician as Attending)8116 - Incomplete Medical Records Form (Physician as Consultant)8117 - Delinquent Medical Records8118 - Delinquent Medical Records Sample Letter8119 - Physician's Notice of Delinquent Charts Form8120 - Notice of Upcoming Suspension for Incomplete Medical Records - Sample Letter8121 - Medical Staff Suspension List8122 - Physicians Suspension Log8123 - Phone Log - Physicians Off Suspension8124 - Medical Record Assembly8125 - Assembly Order of Emergency Department Medical Records8126 - Assembly Order of Medical Surgical Medical Records8127 - Assembly Order of Newborn Medical Records8128 - Assembly Order of Obstetrical Medical Records8129 - Assembly Order of Outpatient Autologous Blood Draw8130 - Assembly Order of Outpatient Surgery Medical Records8131 - Assembly Order of Pain Management Medical Records8132 - Assembly Order of SNF Medical Records8133 - Permanent Filing and Retention of the Medical Record8134 - Incomplete Record Filing8135 - Incomplete Medical Record Removal8136 - Medical Record Retention8137 - State Hospital Association Record Retention Recommendations8138 - Intentional Destruction of Medical Records8139 - Multiple Volume Medical Records8140 - Regulations for Off-Site Record Storage8141 - Off-Site Centralized Storage of Inactive Patient Records8142 - Record Receipt for Off-Site Storage - Sample Receipt and Agreement8143 - Expense Sheet for Off-Site Storage8144 - Delivery Charges - Sample Form8145 - State Department of Health Services Licensing and Certification - Program Flexibility Request Form8146 - Medical Record Review Function8147 - Medical Record Review Tool - Sample Form8148 - Medical Record Review - Point of Care8149 - Data Collection - Analysis Desk8150 - Analysis Worksheet8151 - Dictation Report Data Collection Performance Improvement8152 - Transfer Medical Records Data Collection Performance Improvement8153 - Admission Assessment - SNF Departments Performance Improvement8154 - Patient Self-Determination Act Data Collection Performance Improvement8155 - Conditions of Admission Data Collection Performance Improvement8156 - Physician Orders Audit - SNF Medical Records Performance Improvement8157 - Transcription8158 - Transcription Service: New Surgery Schedules, Add-on Surgeries, Changes in Surgery Schedule8159 - Contract Example for Transcription Service