Medical Records Department
The Medical Records Department is open
from 7:00 a.m. to 5:00 p.m. Monday through Friday except on holidays.
The Medical Records Department is responsible for
overseeing the timely processing, completeness, and retrieval of all patient medical records. A
medical record is maintained on every patient treated at the facility and medical record services
are provided to all areas of the facility. Medical record services include provision of an accurate
patient record with emphasis on the following:
abstracting, analysis, and coding
Transcription of appropriate reports for the medical
Record retrieval, filing, and storage
Observation of patient needs and
changes in legal and regulatory requirements are used to identify services to be provided and
changes to be made to existing services.
Release of Information – Federal
regulations, state laws, and AHIMA guidelines are used to determine compliance when responding to
Birth Certificates – State law regarding completion and filing of birth
certificates are used to determine compliance when registering birth information.
Transcription – Federal regulations, state laws, AAMT guidelines, and physician requests are
used to determine transcription services.
Tumor Registry – State law for
reporting cancer cases is used to determine compliance. In addition, requests by the Tumor Board
influence other registry services.
Coding and Abstracting – Federal regulations,
state laws, and AHA guidelines are used to determine compliance.
Improvement – CMS and state programs are followed when possible along with the specific
hospital driven program to determine the quality of services rendered.