Health Information Management

The Health Information Department is conveniently located near the main lobby of the Center and is comprised of staff who have knowledge and education in the areas of medical record coding, documentation, and health information technology. 

The department is staffed Monday – Friday 7:00 a.m. to 4:30 p.m.  Patients who have received services at the Center and wish to have access to his or her health information may receive instruction on the Center’s procedures in this regard by call the Center’s main telephone number (269) 965-3206, and asking for the Health Information Department at extension 4530.

Your Medical Record

To receive quality healthcare, accurate and timely health information is required. Your health information -- frequently referred to as medical records -- serves the following purposes in the delivery of quality care:

• Basis for planning your care and treatment
• Means of communication for the many health professionals who contribute to your care
• Legal document describing the care you received
• Verification of services and treatment covered by your insurance
• Basic data for health research and planning

The healthcare professionals who care for you compile your health record. Your record is maintained by trained health information management professionals, who are responsible for assuring that your health information is complete, confidential, and available when needed.

Your Health Record

Who owns your record? The health record is the physical property of the Center. However, the fact that the Center owns the physical record does not prevent you from submitting legitimate claims to access it. If you would like to access your health record, contact the Health Information Department at the Center.

Once you have obtained a copy of your health record, you may have questions about its contents. Direct specific questions about your medical care and treatment to your doctor.

You should be aware that law protects the privacy or confidentiality of your record. You can play a part in protecting the privacy of your health information by first knowing what health information is being collected about you and by whom. Access, content, confidentiality -- knowledge of these important aspects of your health information, helps you become an informed healthcare consumer. You may also wish to keep a personal record at home to assure you have ready access to your health information.

Accessing Your Health Record

There are many good reasons why you should have access to your health record including:

• Verifying information and charges for your care
• Knowing what is released when you authorize disclosure of your records to other parties such as employers and insurance companies
• Being able to provide your past medical history and treatment to new healthcare providers

Before you make a request for your record, be aware that state laws vary in the amount of access they give to patients seeking copies of their health information. Fortunately, most healthcare providers allow patients to obtain copies of their health record. If you run into difficulty, check with the Department of Michigan's Community Health for specific regulations. You have a right to access your record under the federal Privacy Act of 1974 (5USC Section 552a), if you received care in a federal medical facility.

When you want copies of your health record, contact the Health Information Department at Southwest Regional Rehabilitation Center. You will need to make your request by completing a standard release of information form or writing a letter. Be sure to include your full name, date of birth, address, and approximate dates of service. This will help us locate your record.

The Center will charge you a fee for locating and copying your record if it is for personal use.  If the record is for continuing care, there is no charge.  You can save money by asking for recent information rather than the entire chart or requesting specific documents within your record such as medication list, most recent history and physical, consultations, and discharge summaries. If the records are for continuing care, there is no charge.

Your Health Record - Understanding its Contents

The specific content of your health record depends on the type of healthcare you have received. The following describes documents common to most health records and additional documents that accompany hospital stay. Be sure to direct specific questions about your care.

Documents Common to Most Health Records

• Identification Sheet is often a form originated at the time of registration. The form lists your name, address, telephone number, insurance type, and policy number
• Medication Record is a list of medicines that have been prescribed or given to you. This form often lists any medication allergies you may have
• History and Physical is a document that describes any major illnesses and surgeries you have had, any significant family history of disease, your health habits, and current medications. In addition, it usually documents your height, weight, blood pressure, pulse, respiration, and any symptoms you have described
• Progress Notes are notes made by the doctors, nurses, therapists, and social workers caring for you that reflect your response to treatment and their observations and plans for continued treatment
• Consultation is an opinion about your condition made by a physician other than your primary care physician. Sometimes a consultation is performed because your physician would like the advice and counsel of another physician. At other times, a consultation occurs when you request a second opinion. A consultation may look like a letter or may be recorded on a specific consultation form
• Physician's Orders are contained in a document with your physician's directions to other members of the healthcare team regarding your medications, tests, diet, and treatments
• Imaging and X-ray Reports are documents describing x-ray results, ultrasounds, or scans.
• Electrocardiogram (ECG, EKG) is the interpretation of graphic tracings that represent the electrical changes in the heart as it beats
• Lab Reports describe the results of tests conducted on body fluids and waste products such as blood, sputum, and urine. Common examples would include a throat culture, urinalysis, cholesterol level, and complete blood count (CBC). Surprisingly, your health record does not usually contain your blood type. Blood typing is not part of routine lab work. When you donate blood, the blood bank usually provides you with a card indicating your blood type. Should you lose your card, most blood banks maintain a record and can tell you your blood type
• Correspondence are letters exchanged between you and the Center, and  inquiries made by your insurance company about the care you received.
• Authorization Forms include copies of consents for admission, and treatment, and release of information
• Graphic Sheet is generally a graph used to plot your temperature, pulse, respiration, and blood pressure over some period of time
• Discharge Summary is a concise summary of your stay including the reason for admission, significant findings from tests, procedures performed, therapies provided, response to treatment, condition at discharge, and instructions for medications, activity, diet, and follow-up care

Your records may contain some or all of the forms above.

Protecting the Confidentiality of Your Health Record

Keeping your health record confidential is an important responsibility of healthcare professionals, but there are several things you can do to help too. You should first be aware of what health information is being collected about you and by whom. Remember, even workplace clinics and employer-sponsored wellness and employee assistance programs may maintain health information about you. Find out who is in charge of that information, and ask about safeguards they use to keep it confidential. Take time to read the fine print before you authorize release of information. The authorization should specify who is to receive your health information and the purpose of its use. The authorization should be limited in scope. In other words, think carefully before you sign an authorization form granting another party the right to see "any and all" of your health record. Do they really need all information or simply information about a particular episode of care.

You may wonder what effect computerization has on the confidentiality of your health record. It's important to remember that manual record keeping systems present many of the same risks to confidentiality as computerized systems. The keys to confidentiality are well-trained staff, sound policies and procedures, and security safeguards. In many ways, well-designed computerized health information systems offer better protection than "file-drawer" storage systems, by imposing technological barriers such as passwords and encryption.

Keeping Your Own Record

Maintaining a personal health record at home is one of the best ways to assure that you will have access to your health information. Keeping a personal health record can be as simple as maintaining a file folder in which you keep relevant medical data.

Individuals with special medical conditions such as diabetes, hypertension, or heart conditions should consider wearing an alerting device to inform others of their condition in an emergency.

 

Southwest Regional Rehabilitation Center 393 E. Roosevelt Battle Creek, Michigan  49017 269.965.3206