Showing posts with label Medical Records. Show all posts
Showing posts with label Medical Records. Show all posts

Even Though You Have Access (Video)

Even though you have access to the patients' personal private medical information, you shouldn't look at it. 

HIPAA is drummed into those of us who work in the medical field, but for some people, the fear of fines and possible jail time doesn't scare them. 

Getting Charts Ready for Medical Records (Video)

When a patient is discharged and you break down the chart, where do you keep the paperwork for Medical Records to come and get?

I’ll give you a hint in the video above.  

When a Patient Wants a Copy of Their Medical Records (Video)

Whenever a patient wants a copy of their medical records, usually the patient, family member or nurse will ask for a Medical Record Request Form.   

They can either fill out the form and take it down to the Medical Records Department themselves and get their own medical information once they're discharged. 

Or they can fill out the form and give it to you for you to place it directly on the front of the chart. Usually, the patient will write the address where they want the medical records sent (their doctor or themselves). By placing it directly on the front of the chart, when you break the chart down, the first thing that Medical Records will see is that form request and they can get right on top of it.   

Requesting Medical Records From Another Facility (Video)

These are the steps that I take once a doctor enters an order to get medical records from another facility.  

  • Grab the Medical Records Request form. Place a patient label on the form.
  • Write the name of the facility, the city, and the state where it is located, the telephone and fax number. If necessary I'll call the facility and verify the Medical Records Department's fax number or verify by looking on their website. 
  • Fill in the patient's name and Date of Birth. I do not put the patient's Social Security number on the form, even though there's space for it. 
  • The date that the patient was in that facility.
  • I'll write the name of the requesting doctor and what type of record they are requesting  (lab results, x-ray results, discharge summary, etc).
  • I then hand the form to the nurse and wait for them to bring it back to me signed. Once it's signed, I'll get a fax cover sheet, fill in the required information and then fax it. 
  • Once I get a fax confirmation sheet, I'll staple all 3 pieces of paper together and place it in the front of the patient's chart. 
  • Sometimes the other facility will fax the paperwork back to the unit and sometimes they'll fax it to the Medical Records Department within the hospital.