(Formerly Medical Records Management)
HEALTH INFORMATION MANAGEMENT
Information is the lifeblood of the health care delivery system. The medical record, in manual or automated form, houses the medical information that describes all aspects of every consumer’s care.
Physicians, nurses, and other health care providers require health information for treating a consumer. The medical record serves as a communication link among caregivers. Documentation in the medical record also serves to protect the legal interests of the consumer, health care provider, and the Guam Behavioral Health and Wellness Center. Medical records are important to the financial well being of our facility as they substantiate reimbursement claims. Other uses of medical records include provision of data for medical research, education of health care providers, public health studies, and quality review. (10th edition Health Information Management)
Understanding Your Medical Records
To receive quality healthcare, accurate and timely health information is required. Your health information referred to as medical records serve—the following purposes in the delivery of quality care:
During your care, the healthcare professional compiles your health record. Your record is maintained by health information management professionals who are responsible for assuring that health information is complete, confidential, and there when you need it.
Basis for planning your care and treatment
Legal document describing the care you received.
Basic data for healthcare funding, research and planning
Means of communication for the many health professionals who contribute to your care.
Your Health Record
Who owns your medical records? The health record is the physical property of the Guam Behavioral Health and Wellness Center. However, the fact that the provider owns the physical record does not prevent you from submitting a request to access it. If you would like to access your health record, contact your doctor or social worker or the Medical Records Branch.
Access, content, confidentiality—knowledge of these important aspects of your health information is vital in becoming an informed healthcare consumer.
Accessing Your Health Record
There are many good reasons why you should have access to your health record including:
Before you make a request for your health record, be aware that departmental policies and procedures, federal and territorial laws vary in the amount of access.
Verifying information and charges for your care
Knowing what is released when you authorize disclosure of your records to other parties
Being able to provide your past medical history and treatment to new healthcare providers for continuum of care.
Establishing and updating a personal health record.
When you request copies of your health record, contact GBHWC’s Medical Records Branch, you will be required to complete a standard Consent To Release Confidential Information Form. Be sure to complete the form in its entirety to avoid delays. Requesting for recent information rather than the entire chart or requesting specific documents such as summaries or medication forms will save you time and money as we may charge you a fee.
Content: Documents common to most health records
Intake Screening and Evaluation is a form originated at the time of registration. This form lists your basic demographic information, provisional diagnosis and treatment recommendations.
Master Treatment Plan is a form listing specific treatment goals and objectives.
Medication Record is a list of medicines that have been prescribed or given to you. This form also contains medication allergies you may have.
Integrated Progress Notes are notes made by the doctors, nurses, social workers and others in caring for you. Your response to treatment and their observations and plans for continued treatment.
Physicians Orders are specifically for your physician's directions to other members of your healthcare team regarding your medication, tests, diet and treatment.
Protecting the Confidentiality of Your Health Record
Keeping your health record confidential is an important and ethical responsibility of healthcare professionals and listed below are 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 workplace, clinics and employer-sponsored wellness and employee assistance programs may maintain information about you. Find out who is in charge of that information, and ask about safeguards they use to keep your information confidential.
Take time to read the fine print before you consent to release your health information. The consent should be specific to the type and time period of your intended purpose. The consent should be limited in scope and think carefully before you sign the consent form that grants another party the right to view and/or receive “any and all documents”. A simple question to ask yourself is “do they really need all information and also could they do with less such as the only a date of service?
Where are we going with your health record?
GBHWC collects and stores your health information into an electronic medical record system using the Tier program. You may wonder what effect computerization has on the confidentiality of your health record. It’s important to remember that manual record keeping systems presents many of the same risks to confidentiality on computer systems. Some of the security measures as well-designed computerized health information systems offer better protection than file catalog systems, by imposing technological barriers such as passwords and encryption.