Health Care Department Operations Manual

Cancel

Chapter 2 – Patients’ Entitlements and Responsibilities

Article 3 – Health Information Management

View All Sections >

2.3.10 Health Record Exception Process

  • Policy

    • California Correctional Health Care Services Health Information Management (HIM) shall ensure the Error Process is utilized to help mitigate and correct scanned documents that may have been misfiled or have other documentation errors in the health record.

  • Purpose

    • To ensure the health record is accurate.

  • Applicability

    • This policy applies to HIM and Exception Processing Team (EPT) staff who are responsible for correcting scanned patient health documentation.

  • Policy Responsibility

    • Under the direction of the Deputy Director, Medical Services, HIM Headquarters, Institution Health Records, and Health Records Center staff are responsible for the oversight, implementation, monitoring, and evaluation of this policy.

    • The Chief Executive Officer, or designee, Health Records Technician III, and Health Records Technician II of each institution are responsible for the implementation, monitoring, and evaluation of this policy.

  • Procedure Overview

    • CCHCS HIM shall ensure staff is knowledgeable of the EPT process. The Exception Types include:

    • Document belongs to a different California Department of Corrections and Rehabilitation number.

    • Document is filed in the wrong Tab.

    • Document is filed in the wrong Sub Tab.

    • Wrong Document Type.

    • Wrong Encounter Date.

    • Other.

  • Procedure Responsibility

    • Under the direction of the Deputy Director, Medical Services, and the Chief of HIM, the EPT is responsible for making all necessary corrections to the health record.

  • Procedure

    • The EPT process is utilized when the health record user discovers an error in scanning (i.e., the document is scanned to the wrong Tab or Sub Tab or the document is placed in the wrong health record) at which time the user shall file/send an exception report to the EPT.

    • All reported exceptions shall be reviewed and processed by the EPT.

  • References

    • Hewlett Packard, Exception Process Manual, Draft (Version 0.1, 2010)

  • Revision History

    • Effective: 08/2016