HEALTH INFORMATION MANAGEMENT

PHILOSOPHY

Health Information Management at Spring Grove Hospital Center shall continually strive to achieve excellence in health care information processing for the documentation of high quality patient care.

1. To strive toward the development of the medical record as a chronologically accurate source document of patient care and treatment.
2. To assure record keeping practices are in conformance with accreditation, regulation and licensing standards.
3. To communicate policies and procedures in such a manner that staff are well oriented.
4. To maintain optimal custodial management of all patient records and files.
5. To maintain confidentiality of patient information.
6. To promote the highest level of staff performance.
7. To encourage staff involvement in inservice, outservice and training programs as necessary to update skills and performance.

CONFIDENTIALITY STATEMENT AND AGREEMENT

As a condition of employment in the Health Information Management Department of Spring Grove Hospital Center, a potential employee must be willing to sign the following agreement:

"As a condition of employment in the Health Information Management Department of Spring Grove Hospital Center, I agree to abide by the rules of confidentiality as dictated by Federal and State authorities when handling the medical record of patients presently in the hospital and those who have been discharged. Further, I will not discuss either by name or inference any information concerning treatment, diagnoses, and demographic or social data pertaining to patients in the hospital or those who have discharged. I also understand that it is a federal offense, punishable by fine or imprisonment to divulge information from the medical record of a patient presently under treatment at Spring Grove Hospital Center or a former patient without the written consent of the person to whom it pertains or the consent of a legally appointed guardian or representative acting on the behalf of a patient or former patient. Also, I will not deny or confirm the whereabouts of any patient admitted to this hospital unless a MISSING PERSON report has been filed by the interested party or parties."

OVERVIEW OF THE DEPARTMENT

Hours or operation for Health Information Management are from 8:00-5:00, Monday thru Friday, excluding holidays. The office in the Dayhoff is open six (6) days a week.

Central Health Information Management is located in the Smith Building where all records of discharged patients are kept.

Health Information Management offices are located in each patient care building on the grounds of Spring Grove Hospital Center. All master charts of patients who have more than one admission to the hospital are maintained in the HIS office for patients in that building. The responsibility of the HIS staff person is to handle all transcription for psychiatrists, social workers, and psychologists. All requests for information on inpatients are handled by the person assigned to the area. Monthly and quarterly statistics for aftercare, admissions and discharges are gathered and distributed by HIS staff for the purpose of assisting in patient care. The department is very much involved in the computerization of the medical record as plans move forward for a completely automated patient record. HIS plays an integral part in the ORYX program as mandated by JCAHO, assisting in data entry on a daily basis..

To gain access to medical records in the Health Information Management offices, proper identification is required in the form of a state ID if an employee, driver license or other form of picture identification.

CONFIDENTIALITY OF THE MEDICAL RECORD

By federal and state law, the medical record of any person admitted to a mental institution is confidential and does not fall under the general disclosure laws for general hospital admissions.

The staff of the Health Information Management department at Spring Grove take every precaution to insure that the medical record is kept confidential. No one is allowed access to information in the medical record unless they are part of the treatment team..

A patient or the legally appointed representative of a patient may have access to the information in the medical record by following the proper procedure. In the event access is not granted, by law, a summary of the record must be made available if the interested person requests it in writing.

Before signing an Authorization for Release of Information, a patient or former patient should read it very carefully, to insure that no more information is disclosed than is authorized. For some information released, a processing fee will be charged.

RETENTION OF MEDICAL RECORDS

Medical records in psychiatric facilities in the State of Maryland are maintained for a period of 25 years after the last discharge. They are housed at the facility for 15 years and sent to the State Archives for 10 years and then destroyed.

The only exceptions are records of patient who have died and are only at the hospital on an (O)bservation (S)tatus. Death records are kept for 10 years and then destroyed; OS records are kept for 6 years and then destroyed

STAFF COMPETENCY

Health Information Mangement is directed by an individual who meets the State of Maryland's established qualifications for the classification of Health Records Program Manager.

All staff permanently assigned to Health Information Management must complete an orientation period. This consists of but is not limited to confidentiality of patient information, policies and procedures, performance improvement activities and medical record documentation requirements. At the end of orientation, the person is required to sign a statement of completion and understanding. Supervisors are to discuss at least one policy or procedure at each of their staff meetings. At the quarterly meetings, educational quizzes or in-services are conducted.

Since Health Information Mangement at Spring Grove Hospital Center is a very diversified department, staff assigned to work in the Health Information Management offices must have a working knowledge of medical terminology or be willing to take a course. They must be able to transcribe at least 50 words a minute. Staff are trained to use the coding manuals (ICD-9-CM and DSM-IV). Education in psychiatric record keeping is ongoing.

STUDENT TRAINING

Health Information Management is part of an ongoing student training program here at the hospital. Students are referred mostly from the Baltimore City Community College although some have been referred from Essex Community College in the past when they had the Health Information Technology Program.

FUTURE PLANS

Health Information Management will move forward with plans to take further advantages of advancements in health information technologies. This will be done in an effort to better serve our internal customers, the patients, staff and outside agencies.