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Health Information Management (HIM)
Phone: (970) 564-2311
Fax: (970)
564-2333
e-mail: himdir@swhealth.org
As a way of
meeting the mission of providing high quality health care to our community,
the Health Information Management (HIM) department maintains your health
records so they are available when your health care provider needs them.
Every encounter a patient has with the hospital, whether an overnight
stay, day surgery, an emergency room visit or a simple x-ray, results in a
record that must be processed, coded for reimbursement and maintained.
In addition to managing records, the HIM department provides
information to State and Federal agencies as required.
The
HIM department is open to the public 8:00 A.M. to 5:00 P.M., Monday through
Friday.
Frequently asked questions:
Whose property is the health record?
The
patient’s original health record is the property of Southwest Memorial
Hospital. The content
(information) belongs to the patient. However, patients have a
right to a full, complete and legible copy of their health records.
How long are the records kept?
For adults,
Colorado law requires the health records to be kept as an original or on
microfilm for no less than ten years after the most recent patient care
usage, after which time records may be destroyed at the discretion of the
Hospital. Health records of minors are kept for the period of minority plus
10 years (i.e. 28 years less the age of the minor at the time of the most
recent patient care usage).
How can I be assured my records are confidential?
The hospital has a mechanism for maintaining the security and confidentiality of data and information contained in the health record and is especially careful about preserving the confidentiality of sensitive data and information.
Who can get copies of my records?
Generally, only
the patient may obtain copies of health records, or in the case of minors, a
parent or legal guardian. Information related to drug/alcohol abuse,
psychiatric problems, HIV or Aids receives special consideration under
additional State and Federal regulations.
The hospital requires a Release of Information form to be signed by
the patient prior to release of any copies. There are some exceptions; below are some examples. However, if you have specific
concerns, please feel free to call the HIM department
Public
Health Department: Records
for established contagious diseases may be released without consent of the
patient; however, proper written request must be placed onto chart.
Coroner:
Any records, which pertain to a Coroner’s Investigation, may be
released without consent.
Patient
Primary Insurance:
All require proper written request, however, these do not require
signed release by patient. Our
"Conditions of Admission" now states health record information can
be released to primary insurance companies for requisition of payment.
Government Agencies:
Requests for records made of SWMH as a Medicare/Medicaid Participating
Hospital do not require patient consent.
Contents of Health Record
Health records are reviewed on an ongoing basis for completeness of information, and action is taken to improve the quality and timeliness of documentation that impacts patient care.
Very rigid standards apply as to the content of the health record and must contain very specific data and information, including:
· the patient's name, address, date of birth, and the name of any legally authorized representative;
· the legal status of patients receiving mental health services;
· emergency care provided to the patient prior to arrival, if any;
· the record and findings of the patient's assessment;
· conclusions or impressions drawn from the medical history and physical examination;
· the diagnosis or diagnostic impression;
· the reasons for admission or treatment;
· the goals of treatment and the treatment plan;
· evidence of known advance directives;
· evidence of informed consent, when required by hospital policy;
· diagnostic and therapeutic orders, if any;
· all diagnostic and therapeutic procedures and test results;
· all operative and other invasive procedures performed, using acceptable disease and operative terminology that includes etiology, as appropriate;
· progress notes made by the medical staff and other authorized individuals;
· all reassessments and any revisions of the treatment plan;
· clinical observations;
· the patient's response to care;
· consultation reports;
· every medication ordered or prescribed for an inpatient;
· every medication dispensed to an ambulatory patient or an inpatient on discharge;
· every dose of medication administered and any adverse drug reaction;
· all relevant diagnoses established during the course of care;
· any referrals and communications made to external or internal care providers and to community agencies;
· conclusions at termination of hospitalization;
· discharge instructions to the patient and family; and
· clinical resumes and discharge summaries, or a final progress note or transfer summary.
Upon discharge all this information must be assembled and completed within a specific time frame.
Medical Transcription
The Medical Transcriptionist also makes a definitive contribution to the quality of the patient’s health record. The transcriptionist is a health language specialist who interprets and transcribes dictation by physicians and other healthcare professionals regarding patient assessment, workup, therapeutic procedures, clinical course, diagnosis, prognosis, etc., editing dictated material for grammar and clarity, as necessary and appropriate. The SWMH HIM department has three full time and one relief transcriptionists who provide seven-day per week coverage.
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1311 N. Mildred Rd. • Cortez, Co, 81321
Main Hospital: 970-565-6666 • Emergency Room: 970-564-2025
