It's 8:30 p.m. as a concerned mom pulls into the parking lot at Capital Health Plan’s Urgent Care center in Northeast Tallahassee. Mom explains that her 5-year-old son has been ill most of the day and has a fever that peaked at 102 degrees. She tried treating the fever at home but couldn’t get it to come down. The physician enters the exam room, completes an assessment of the boy, and begins entering notes. It’s when those first notes are entered that the work of a Health Informatics and Information Management (HIIM) professional begins.
HIIM professionals have a responsibility to uphold the privacy, security, and integrity of each patient medical record from the beginning until the very end. However, it’s not their responsibility alone – this protection is part of a collective effort shared among physicians, clinical staff, administrators, and information technology professionals alike. Each of these individuals plays an integral role in protecting the privacy of your medical records.
While much of what these professionals do happens behind the scenes, their work is critical to CHP’s (and any other health organization’s) overall success. HIIM professionals, including Electronic Health Record Technicians and Electronic Health Record Specialists, help ensure that patient records are properly organized and documentation is accurately and promptly scanned and indexed into the patient’s chart, allowing access to multiple health care professionals who may need the information. Coders, also HIIM professionals, work hand in hand with clinical staff to ensure that the patient’s medical record is accurate, not only for payment but for continuity of care. And when members request a copy of their medical records, an HIIM Release of Information professional will ensure that everything is complete and issued within legal guidelines.
No matter a person’s role within the Health Informatics and Information Management profession, whether entry level or management, the responsibility of HIIM professionals remains the same: to organize, oversee, and uphold the integrity of the patient medical record.
Capital Health Plan - Medical Records Frequently Asked Questions
Q1. How do I request a copy of my medical record?
A1. In order to obtain a copy of your medical records, you must complete a medical record request form. You may request a copy of this form from the physician’s office you’d like to request the records from.
Q2. In what formats may I request my medical records?
A2. The Privacy Rule (45 CFR 164.524) grants patients the right to receive their medical records electronically or in their preferred form or format as long as the physician practice has the ability to readily produce it in that format. If it cannot be produced, a hardcopy or another format agreed upon by both the member and the provider can be given. Other formats offered include USB, CD-ROM, Secured Email, and/or Application Programing Interface (API). Application Programming Interface (API) is an interface used to make it easier for patients to access and share their protected health information. Contact your physician’s office for more information about APIs. /p>
Q3. Who may access my medical records?
A3. Your medical records can be requested by you as the patient, your legal representative, your health care provider, and clinical staff responsible for your care. There are limited circumstances under which other third parties may access your medical records without authorization, including in cases of continuing care, medical review, and/or for legal purposes.
Sourced By: Healthwise
Reviewed By: Capital Health Plan Physicians Group