Health Care Department Operations Manual

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Chapter 2 – Patients’ Entitlements and Responsibilities

Article 3 – Health Information Management

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2.3.7 Health Record Viewing and Scanning

  • Policy

    • California Correctional Health Care Services (CCHCS) Health Information Management (HIM) shall ensure all paper documents received are scanned in a timely manner and readily accessible in the health record for viewing to support continuity of care.

  • Purpose

    • To ensure availability of patient health information.

  • 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 ensure all staff are informed of and follow established rules and guidelines for scanning patient health information.

  • 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 procedure.

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

  • Procedure

    • HIM staff shall scan Day Forward Documents received within 24 hours of receipt.

    • HIM staff shall scan urgent/emergent documents immediately upon receipt.

    • Specialty Reports shall be scanned into the chart within five calendar days from the date of the patient encounter.

    • Hospital records (outside facility) shall be scanned into the chart within three calendar days from the date the patient is discharged.

    • HIM staff shall combine multiple documents into a single PDF.

    • HIM shall index and perform quality checks prior to uploading the document(s) into the health record.

    • HRC staff is responsible for scanning archive documents that are housed at the HRC.

  • References

    • California Correctional Health Care Services, eUHR Initiative Daily Scanning Specification Document (Version 1.1, 2010)

  • Revision History

    • Effective: 08/2016