{"id":716,"date":"2023-10-23T13:25:44","date_gmt":"2023-10-23T20:25:44","guid":{"rendered":"https:\/\/www.cdcr.ca.gov\/hcdom\/?post_type=dom&#038;p=716"},"modified":"2024-05-21T12:26:09","modified_gmt":"2024-05-21T19:26:09","slug":"2-3-1-health-information-management-overview","status":"publish","type":"dom","link":"https:\/\/www.cdcr.ca.gov\/hcdom\/dom\/chapter-2-patients-entitlements-and-responsibilities\/article-3-health-information-management\/2-3-1-health-information-management-overview\/","title":{"rendered":"2.3.1 Health Information Management Overview"},"content":{"rendered":"\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Policy<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>California Correctional Health Care Services, Health Information Management shall:<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Ensure availability of accurate and complete patient health care information to authorized users.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Ensure quality of patient health related information.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Ensure privacy and security of patient health information.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Ensure access to health records to support patient health care needs.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Ensure appropriate quality controls and other monitoring mechanisms for all ambulatory, inpatient, and outpatient documentation.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Manage the release of Protected Health Information, to include use and disclosure and other release of information processes and functions.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Ensure appropriate coding such as International Classification of Diseases is completed for all inpatient admissions.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Purpose<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>To ensure maintenance, storage, retrieval, accessibility, retention, and destruction of patient health information. \u201cThe legal health record is the documentation of healthcare services provided to an individual during any aspect of healthcare delivery in any type of healthcare organization\u201d (American Health Information Management Association: Fundamentals of the Legal Health Record and Designated Record Set). \u00a0Patient records consist of paper-based records, electronic records, and other media that documents the patient\u2019s health care.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Responsibility<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Under the direction of the Deputy Director, Medical Services, the Medical Record Directors at headquarters are responsible for the oversight, implementation, monitoring, and evaluation of this policy through consultation services pursuant to Title 22.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>References<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Code of Regulations, Title 22, Division 5, Chapter 9, Article 4, Section 77139, Health Record Service; Section 77141, Health Record Content; and Section 77143, Health Record Availability<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>American Health Information Management Association (AHIMA):  <em>Health Information Management Technology, An Applied Approach <\/em>(Fourth ed., 2013)<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>American Health Information Management Association (AHIMA):  <em>Fundamentals of the Legal Health Record and Designated Record Set:<\/em> <a href=\"http:\/\/library.ahima.org\/xpedio\/groups\/public\/documents\/ahima\/bok1_048604.hcsp?dDocName=bok1_048604\">http:\/\/library.ahima.org\/xpedio\/groups\/public\/documents\/ahima\/bok1_048604.hcsp?dDocName=bok1_048604<\/a><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Hospital Association Consent Manual, 2010, Chapter 15-17, A Reference for Consent and Related Health Care Law (37th ed., 2010)<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Institute of Medicine. Key Capabilities of an Electronic Health Record System: Letter Report (2003)<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Health Care Department Operations Manual, Chapter 2, Article 2, Confidentiality and Privacy<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Revision History<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Effective: 01\/2002<br>Revised: 08\/2016<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t","protected":false},"parent":92,"template":"","class_list":["post-716","dom","type-dom","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>2.3.1 Health Information Management Overview - Health Care Department Operations Manual (HCDOM)<\/title>\n<meta name=\"robots\" content=\"noindex, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"2.3.1 Health Information Management Overview - Health Care Department Operations Manual (HCDOM)\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.cdcr.ca.gov\/hcdom\/dom\/chapter-2-patients-entitlements-and-responsibilities\/article-3-health-information-management\/2-3-1-health-information-management-overview\/\" \/>\n<meta property=\"og:site_name\" content=\"Health Care Department Operations Manual (HCDOM)\" \/>\n<meta property=\"article:modified_time\" content=\"2024-05-21T19:26:09+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-2-patients-entitlements-and-responsibilities\\\/article-3-health-information-management\\\/2-3-1-health-information-management-overview\\\/\",\"url\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-2-patients-entitlements-and-responsibilities\\\/article-3-health-information-management\\\/2-3-1-health-information-management-overview\\\/\",\"name\":\"2.3.1 Health Information Management Overview - Health Care Department Operations Manual (HCDOM)\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/#website\"},\"datePublished\":\"2023-10-23T20:25:44+00:00\",\"dateModified\":\"2024-05-21T19:26:09+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-2-patients-entitlements-and-responsibilities\\\/article-3-health-information-management\\\/2-3-1-health-information-management-overview\\\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-2-patients-entitlements-and-responsibilities\\\/article-3-health-information-management\\\/2-3-1-health-information-management-overview\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-2-patients-entitlements-and-responsibilities\\\/article-3-health-information-management\\\/2-3-1-health-information-management-overview\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"HCDOM\",\"item\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/\"},{\"@type\":\"ListItem\",\"position\":3,\"name\":\"Chapter 2 &#8211; 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