Medical Record Retrieval and Follow-Up for Release of Protected ...

Release of Information Policy Manual
Policy: M-05-ROI
Health Information Management Page 1 of 3
LSU Health Sciences Center-Shreveport, LA
Reviewed: 2/13
Revised: 10/97, 12/06, 12/08
MEDICAL RECORD RETRIEVAL AND FOLLOW-UP
FOR RELEASE OF PROTECTED HEALTH INFORMATION
PURPOSE:
To provide guidelines for the timely retrieval of medical records and medical record loose
information needed to respond to outside requests for release of protected health information.
POLICY:
The goal is to ensure that 90% of the requests received for the release of protected health
information shall be answered within 7 calendar days.
Follow-up will be performed daily on all records not readily accessible to respond to all requests
in a timely manner.
PROCEDURE:
1. Obtain the mail that constituents the request for protected health information and Disability
Determination from the designated area in the Release of Information section.
2. Log the requests received into the online correspondence log or the disability log.
3. Enter the reservations via the 3M/SoftMed Chart Management system to have the slips
generated to retrieve the medical records.
4. Print the reservation slips out of the 3M/SoftMed Chart Reserve application
A. Select Reports from the Chart Reserve main screen
B. Select List Reports
C. Select the ‘Release of Information’ Report
D. Enter the date needed
E. Remove both check marks from sort by location – one from long term location
and one from locations needed
F. Enter a check mark in the Print Selection area – Include slips already generated
G. Select generate report and print the reservation slips
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Release of Information Policy Manual
Medical Record Retrieval and Follow-Up
For Release of Protected Health Information
Policy: M-05-ROI
Page 2 of 3
5. Obtain the reservation slips and place each slip in a red outguide and sort the outguides in
terminal digit order on the designated shelf in the release of information area.
6. Log the total number of reservation slips received into the release of information log.
7. Retrieve the unit folders and incomplete records (as needed) in terminal digit order,
beginning with 000 and work through 999 in the following manner:
A. Locate the terminal digit section for the medical record requested using the file
guides and/or color coded system.
B. Locate the specific medical record number requested
C. Verify the patient’s name and medical record number on the chart request against
the record in file. If the name and number are not the same, make a notation on the
chart request form indicating wrong #. At the completion of this task, check the
Master Patient Index (MPI) for the correct medical record number and retrieve the
medical record accordingly.
D. Retrieve the medical record
E. Place a copy of the chart request form in the plastic pocket on the front of the
medical record
F. Retrieve any incomplete records and combine with the unit folder when needed
G. Continue this process until all unit folders and incomplete records have been
retrieved.
8. Verify the patient’s medical record number by performing an additional medical record
number inquiry when you are unable to locate the medical record.
9. Verify if you need to obtain additional medical record folders from the following areas:
9 Feist-Weiller Cancer Center Record (FWCC) (VOL F1)
9 Ambulatory Care Center (VOL A1)
9 Women’s Health (VOL W1)
9 Children’s Services (VOL C1)
9 Family Medicine and Comprehensive Care (VOL M1)
If the patient has a medical record folder with any of the above volumes, contact the HIM
area to obtain this volume of the patient’s medical record to assist in responding to the
request for information.
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Release of Information Policy Manual
Medical Record Retrieval and Follow-Up
For Release of Protected Health Information
Policy: M-05-ROI
Page 3 of 3
10. Review any pending requests to determine if the requests can be answered using the
electronic patient record, without the patient’s paper medical record, i.e.,
► Discharge summary -
► Outpatient Visit Note -
►Other Loose Reports -
retrieve a copy of the discharge summary from the
3M/SoftMed’s ChartScript application or from Siemen’s Lifetime
Clinical Record (LCR) or Net Access.
retrieve a copy of the transcribed note from Siemen’s LCR,
SunRise, NetAccess, or 3M/ChartScript application.
retrieve a copy of the report from Siemen’s LCR or the
Laboratory Information System (LIS)
Note: After checking LCR, contact the specific ancillary department to verify services
provided if you are unable to locate a copy of the document to support the
information requested.
11. Contact the Labor Unit for OB information as this information is filed in the prenatal record
until the patient is admitted for delivery. O/B charts shall be returned to the Labor Unit daily.
12. Perform medical record follow-up on all charts remaining for records checked out to the
following areas:
√ Inpatient Nurse Station and ECC
Perform a medical record number inquiry to determine if the patient is currently
in-house. If so document this information on the chart request, contact the requesting
requesting party via mail or by phone, indicating that the patient is currently in-house.
√ Physician’s research
Locate the medical record in the specified physician’s research drawer. Retrieve the
record and place a note in the pocket to return the record to the specific physician’s
drawer.
√ Clinical departments
Locate the medical record on the shelf behind the front desk area. If the chart is not
available on the shelf, contact the clinical department to return the patient’s medical
record.
√ HIM areas
Obtain the medical record form the internal area of the department, i.e., Director’s
Office, Assistant Director’s office, Coding, Lock File, etc…
13. Check the completed admissions and loose reports for any folders not retrieved and
admissions not filed.
14. Follow the procedures on how to locate misfiled charts in situations where the chart is not in
file and you have been unsuccessful in locating any information. If you are still unable to
locate the chart, check the inactive file areas and notify your supervisor for direction.
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