Health Information Management (HIM)
The Health Information Management (HIM) Department (also known as Medical Records) plays a vital role in the patient healthcare setting. HIM is responsible for the storage of all inpatient, observation, same day center charts, emergency department and labor and delivery charts. The department is under the direction of Rita Prather, RHIT, CTR.
The main phone number for the HIM Department is (270) 251-4142.
During the patient's hospital stay, all data collected on the patient is placed within the patient's chart. Once the patient has been discharged, HIM takes charge of the chart. The chart is then assembled in the Universal Chart Order within the HIM Department. Once assembled, the chart proceeds to the analysis stage in which the chart is reviewed for any incomplete physician documentation, such as operative reports, discharge summaries, etc.
After the analysis of the chart is complete, the chart advances to the physicians incomplete area, and the physician(s) involved in the patient's care are to review and complete the chart's documentation. Once completed by the physician(s) involved, the patient's chart is then filed into the permanent medical files.
There are several additional, but just as vital, areas of the HIM Department.
Upon the birth of a child in our facility, the birth certificate coordinator for the HIM Department collects all of the pertinent information related to the mother and child. This information would include items such as the child's name, mother's name, father's name, etc. All of this information is then entered a special software program which generates the child's birth certificate. The birth certificate is then reviewed and signed by the child' s mother and father and then sent to the Commonwealth of Kentucky Department of Health (where it is forwarded it to the Department of Vital Statistics) where the birth is officially recorded.
Release of Information
This area of the HIM Department is responsible for the collection and distribution of medical records requested by patients, physicians, other healthcare facilities, as well as lawyers and insurance companies. As the confidentiality of our patients is of the utmost importance, the release of information clerks are responsible for ensuring the proper authorization for records release are obtained, and the release of records is done in a timely fashion. The hours of operation for release of information is 8:00am - 4:00pm EST, Monday - Friday. The direct phone number for the release of information desk is (270) 251-4142.
The coding area of the HIM Department serves to assist the hospital with the billing for the Emergency Department, inpatient, observation, same day surgery, and clinical records. The diagnoses given to a patient has a specific code assigned to it. The coders will review a patient's chart and assign the proper diagnosis codes to the patient in order for billing to be completed. There are strict federal, state and corporate guidelines that must be followed within the coding department to ensure the proper billing of the patient's hospital stay.
Another vital area of the HIM Department is transcription. The transcription area is responsible for the collection of dictated reports by physicians, as well as the prompt and accurate transcription of the dictated reports. Accuracy is key! Any mistake in transcription would lead to incomplete or incorrect information in the patient chart, leading to inaccurate patient care. The transcription department types all history and physicals, consultations, operative reports, radiology (diagnostic imaging) reports, cardiology reports, neurology reports and procedure reports dictated by the physicians on staff.