Health Care Department Operations Manual

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Chapter 2 – Patients’ Entitlements and Responsibilities

Article 3 – Health Information Management

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2.3.9 Health Record Storage and Retrieval

  • Policy

    • California Correctional Health Care Services (CCHCS) Health Information Management (HIM) shall ensure patient health information is stored and maintained in a secured environment.

  • Purpose

    • To ensure all health record documents are stored in a safe and secure environment from which patient health information can be easily retrievable, available, accessible, and viewable to clinicians.

  • 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 health record documents are stored in a safe and secure environment. Patient health information shall be easily retrievable, accessible, and viewable electronically by clinicians.

  • 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

    • Health Record Document Storage and Retrieval

      • Document Storage

        • HIM staff shall package and ship documents to a designated archive location.

        • All Day Forward scanned documents shall be sent to the HRC for storage.

      • Document Retrieval

        • All scanned documents archived at the HRC shall be stored in an easily retrievable manner.

    • Paper Health Record Storage and Retrieval

      • All paper based health records shall be maintained and stored at the HRC.

      • Documents indexed in the paper health records shall be easily retrievable upon request.

    • Inpatient Paper Health Records

      • The paper health records for inpatient admissions shall be stored in the local HIM Department at the institution where the admissions occurred.

      • The local HIM Department shall be responsible for the maintenance and retrieval of the complete original inpatient chart.

  • References

    • California Code of Regulations, Title 22, Division 5, Chapter 9, Article 4, Section 77143, Health Record Availability

    • California Code of Regulations, Title 22, Division 5, Chapter 12, Article 5, Section 79807, Inmate-Patient Health Record Availability

    • 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