Health Care Department Operations Manual

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Chapter 2 – Patients’ Entitlements and Responsibilities

Article 3 – Health Information Management

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2.3.12 Death Records: Administrative Hold

  • Policy

    • California Correctional Health Care Services (CCHCS) Health Information Management (HIM) shall:

    • Ensure federal and state privacy protections continue to apply to a patient’s health information even after death. These protections also require institutions to release health records to those people either appointed by the patient or who are deemed a personal representative by state law. 

    • Allow authorized users to place a health record on Administrative Hold which prohibits the scanning of additional documents without authorization.

    • Remove Administrative Holds under certain circumstances such as adding documents to the health record.

  • Purpose

    • To ensure the health record is protected after death.

  • Policy Responsibility

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

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

  • Procedure Overview

    • CCHCS HIM shall determine the appropriate release of a deceased patient’s Protected Health Information (PHI) documents.  Federal and state privacy protections continue to apply to a patient’s PHI even after the patient’s death.  These protections also require facilities to release health records to those people either appointed by the patient or who are deemed a personal representative by state law.

  • Procedure Responsibility

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

    • The CEO, or designee, HRT III, and HRT II of each institution are responsible for the implementation, monitoring, and evaluation of this procedure.

  • Procedure

    • Placing an Administrative Hold

      • In the event that a health record needs to be placed on Administrative Hold, the application shall be utilized to allow a Supervisor or authorized user to do so.

    • Removing an Administrative Hold

      • An Administrative Hold can be removed under certain circumstances such as adding documents to the health record.

      • A supervisor or an authorized user may remove an Administrative Hold.

    • Scanning Additional Documents During an Administrative Hold

      • When additional documents need to be scanned and the health record is on Administrative Hold:

      • An HRT II supervisor or a Health Record Technician I (HRT I) who has been designated as the supervisor backup shall remove the Administrative Hold temporarily.

      • HIM staff shall scan the documents.

      • Once the documents are scanned, the chart shall be put back on Administrative Hold.

    • Replacing an Administrative Hold

      • When replacing an Administrative Hold, the health record must remain locked indefinitely.

  • References

    • American Health Information Management Association, Who Has the Rights to a Deceased Patient’s Records? Journal of AHIMA (August 2009)

    • California Hospital Association Consent Manual: A Reference for Consent and Related Health Care Law (37th ed., 2010)

  • Revision History

    • Effective: 01/2002
      Revised: 08/2016