Where to Begin?
Chart Management Assessment- Why?
• What paper charts exist in the network that
aren’t managed by HIM?
• Where are they stored?
• How are they stored?
• How are they retrieved?
• How are they released?
• What EMRs exist from acquired practices?
• Who has access?
• Who maintains from an IT perspective?
• How do we get information for
release of information?
• Off-site storage
IHIMA May 2016
Retention-What is the Policy?
Past
• “Community will keep hard copy of paper medical
record documents for ten (10) years beyond the
age of majority or ten (10) years beyond last visit
date with the Network, which ever comes first.
For inpatient records, the date of visit/discharge
will be used to determine end of activity.
Outpatient activity status will be determined from
last visit date.”
• If a patient has had activity within the last 10
years, Community Health Network had their paper
medical records in Building 10. We could have had
records back to late 50s or 60s if the patient has
remained active in our system.
IHIMA May 2016
Retention-What is the Policy?
Current
• CHNw will maintain a paper or
electronic copy of medical records for a
period of ten (10) years from the date
of discharge for each individual visit.
• 2016 Records Retention Policy
• 10 years
IHIMA May 2016
Our Journey
• Building 10 Medical Records for
Hospital Medical Records and
Outpatient Behavioral Health Medical
Records
IHIMA May 2016
Building 10
IHIMA May 2016
Building 10
IHIMA May 2016
Building 10
IHIMA May 2016
Building 10
IHIMA May 2016
Retention
• Utilized current record storage vendor to
come sort every paper medical record in
Building 10. Each medical record file folder
will need to be reviewed and each visit inside
will need to be reviewed for the following:
• Medical Records Less than or equal to 10
years old
• Medical Records Greater than 10 years old
IHIMA May 2016
Retention
• Destroy the records greater than 10 years
old after entire Building 10 fileroom is
sorted
• Store the medical records less than 10
years old after the sort is completed at our
current off-site storage vendor
IHIMA May 2016
Release of Information
• Larger scope than hospital and physician
practice
• Currently utilize outsource ROI vendor for
disability requests and physician offices
• MedChecks (Urgent Care) and Home Health
process requests themselves
• Others may, too? Need to assess
• Hospitals (CHE, CHS, CHN, CHVH) process
approximately 5,000 requests per month
IHIMA May 2016
Release of Information
• Need for standardization larger than just
Ambulatory
• Amendment request management
• Restriction request management
• Patient ROI requests
• Release of billing information
• My Chart requests for Release of
Information
IHIMA May 2016
HIM and Ambulatory Orders
• HIM is now monitoring the signing of
Ambulatory Orders
• For Hospital Outpatient Visits and
Ambulatory Visits
• Another request from Ambulatory for
HIM Assistance
IHIMA May 2016
Future
• Ambulatory Operational Leaders
continue to request HIM assistance
• We are the experts in HIM
• We need to take the lead and assist our
Ambulatory Peers
IHIMA May 2016
HIM Organizational Structure for the FutureCHNw Discussion
• HIM Ambulatory Manager
• Team of staff to support Ambulatory HIM processes
• Chart Management Assessment in process to
determine staff needs, develop inventory, and gather
information
• HIM Release of Information Manager separate from HIM Chart
Maintenance Manager (same HIM Manager today)
• Additional HIM ROI Coordinator
• Additional Chart Correction Staff (5.0 FTEs)
• 3.0 HIM Data Integrity Specialists and 2.0 HIM Data
Integrity Auditors
• HIM Project Manager
IHIMA May 2016
Contact Information
Cindy Spann, MIS, RHIA, CHPS,
CCS, CCS-P
Phone: 317-355-4193
Email: [email protected]
Questions?