When patients enter a hospital or a rehabilitation facility they are usually concerned with the care they will be receiving from the doctors, nurses and therapists; their treatment plans and eventual outcomes. They usually never think about their “medical record.” Most patients don’t realize that as soon as they enter the registration area of a healthcare facility, either as an outpatient or an inpatient, a medical record is created for them. The medical record contains demographic information, as well as clinical information. The medical record is a legal document that can assist caregivers with their treatment plans and provide better outcomes.
Medical records are important tools in the practice of medicine. They serve as a basis for planning and continuity of care. The medical record provides a means of communication between the physician and other professionals contributing to a patient’s care and they furnish documentary evidence of the course of the patient’s illness and treatment during each hospital encounter.
The make up of the medical record has seen many changes over the years. The medical record has evolved from paper-based records to hybrid records (part paper/part electronic) to ultimately a fully electronic medical record in some institutions. Whatever medium the medical record was created on, it must be kept confidential and secure.
The support services provided by medical records department are assembly/analysis; coding and abstracting of patient data; coordination of physician’s transcription; medical record filing/retrieval and release of information to name a few.
The Medical Record Department also gathers, maintains and reports aggregate information. These statistics are vital in the hospital financial, planning and development areas. All statistics are reported to the Statewide Planning and Research Cooperative System (SPARCS) for compilation for statistics of all Health Care Organizations throughout the state.
The Medical Record Department at Helen Hayes Hospital ensures that a high quality medical record is maintained for every patient treated here.
The HHH Medical Record Department handles the release of patient information through proper and legal authorizations to protect the interests of the patient, health care professionals and the hospital. Patients, or those authorized by a patient, have the right to request a copy of their medical record and can do so by completing an authorization form that can be downloaded from our website. There is a fee associated with some requests. There are many laws governing the release of information in healthcare facilities including how long a medical record is retained. Here at Helen Hayes Hospital, we pride ourselves on ensuring patient satisfaction with regard to the release of information. If you have any questions please visit our website at www.helenhayeshospital.org.
Janet Murgittroyd, RHIA, CCS
Director, Medical Records