Health Care Department Operations Manual

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Chapter 2 – Patients’ Entitlements and Responsibilities

Article 3 – Health Information Management

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2.3.6 Health Record Content and Organization

  • Policy

    • California Correctional Health Care Services (CCHCS) Health Information Management (HIM) shall ensure all health related patient documents are located in the health record. The health record shall be organized systematically to facilitate data retrieval and compilation, and information shall be arranged in an easily accessible format and order.

  • Purpose

    • To ensure all patient health related information is contained in the health record.

  • Policy 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 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 ensure all health care documentation is accurately included in the health record following patient encounters/treatment. The health record shall be organized systematically in order to facilitate data retrieval and compilation. HIM staff shall reference the Organization List when including documents in the appropriate sections of the health record. The Organization List shall be used as a reference tool for training and ongoing maintenance of patient health record documentation.

  • Procedure Responsibility

    • Under the direction of the Deputy Director, Medical Services, the Medical Records Directors at headquarters are responsible for the oversight, implementation, monitoring, and evaluation of this procedure through consultation.

    • The CEO, or designee, HRT III, and HRT II are responsible for ensuring that applicable patient health related information is contained in the health record.

    • HIM supervisors are responsible for ensuring all staff are trained on current policies and procedures related to the organization and placement of documents in the health record.

  • Procedure

    • Chart Organization

      • HIM staff organize documents according to document type and then by encounter/treatment date.

      • Patient identification:

        • Verify the Protected Health Information is referencing the correct patient California Department of Corrections and Rehabilitation (CDCR) number.

        • Verify the CDCR number is on all of the documents.

        • Validate the CDCR number is the same in the health record.

      • Proper placement of documentation in the health record viewer:

        • Refer to the Organization List (on the CCHCS Intranet) for correct placement of all approved health care forms/documents in the health record.

    • Unidentifiable Information

      • HIM staff verify patient identifiers such as name, date of birth, and CDCR number in the CDCR California Incarcerated Records and Information Search and/or Strategic Offender Management System.  If unable to verify the patient identifiers, notify the HIM Supervisor immediately.

  • References

    • California Code of Regulations, Title 15, Division 1, Chapter 1, Subchapter 4, Article 11, Section 1205,  Health Care Records

    • California Code of Regulations, Title 22, Division 5, Chapter 9, Article 4, Section 77139, Health Record Service, and Section 77141, Health Record Content

    • American Health Information Management Association, Documentation for Ambulatory Care (Revised ed., 2001)

    • Health Care Department Operations Manual, Chapter 2, Article 3, Section 2.3.7, Health Record Viewing and Scanning

  • Revision History

    • Effective: 01/2002
      Revised: 08/2016