|The functions and services of HIM include but are not limited to those listed below.|
Maintain a manual of approved medical record policies, procedures, abbreviations and forms that govern the content, documentation and formats for the medical records of the hospital's active and discharged clients; coordinate the process for the review and approval of additions/changes to the manual, which must be approved by the Medical Staff Executive Committee.
Disseminate information and educate appropriate hospital staff about the hospital's policies, procedures and expectations regarding medical records.
Store, safeguard and provide access to the medical records of discharged clients in accordance with applicable laws, rules, policies, procedures and JCAHO standards.
Conduct ongoing reviews/audits of the hospital's medical records, including reviews of the records of all discharged clients, reviews of random samples of active clients, and special/focused audits as requested/indicated; the purpose of the reviews/audits is to identify opportunities for improvement in compliance with established medical record procedures/standards and in documentation in the records.
Code all client diagnoses and medical procedures for billing and for the client information system (Avatar Hospital Information System) and statistical purposes.
Provide medical transcription services to all hospital physicians and to other professional staff as needed.
for the integrity of the information in Avatar (hospital information system),
Upon a client's discharge from the hospital, process documents to provide relevant client demographic and medical information to the designated aftercare agencies to facilitate follow-up and continuity of the client's care; also, prepare the necessary documents when clients are transferred to another facility.
Provide Cancer Registry Reporting to the Georgia Comprehensive Cancer Registry in accordance with the Notifiable Disease Law, Official Code of Georgia (OCGA) Annotated 31-12-2.
with applicable laws, rules, policies, procedures and JCAHO standards
governing the confidentiality, security and integrity of the medical
record and promote compliance hospital-wide.