Abstract
This paper will offer the completion of a site report working to address different questions associated with training that occurred at Portneuf Medical Center two days a week for four hours a day. It will answer questions associated with the learning expectation that was held for this facility, the services provided by the facility, the bed count of the facility, the ownership of the facility, the process for storing medical records, and the departmental functioning in reference to patient record processing and maintenance of health information. It will identify the security measures used by the facility for record control, access, and confidentiality, and the external agencies that regulate the facility, imposing standards for records access. It will describe the activities that I participated in during my time at the medical center, and it will identify the record retention policy of the facility.
Keywords: site report, Portneuf Medical Center, medical records training, summation, observations, report
Site Report: Portneuf Medical Center
The Portneuf Medical Center, located in Pocatello, Idaho treats a wide range of conditions, from the basic care for things like diabetes, depression, or bronchitis, all the way to hantavirus, a virus that reaches level three out of four on the biosafety scale; they offer general surgery services all the way up to surgery through the use of the da Vinci surgical robot (Treatments and Conditions, 2014). The Portneuf Medical Center boasts a total of 174 beds, with an approximate 35,324 patient visits to the emergency room, and approximately 8,188 admissions per year (Portneuf Medical Center, 2014). The LHP is responsible for the Portneuf Medical Center, due to the fact that this is one of the seven hospitals they own.
For the purposes of my training, I spent two days a week, four hours a day, at the Portneuf Medical Center learning about their medical records storage and retrieval process. I expected to learn a little about every position in the Department of Health Information Management, from being a technician working on the support team preparing and scanning charts to working on the customer service side of things analyzing charts, from learning how to be a data integrity specialist to a medical coder, to a manager, to a case coordinator. The majority of the information I learned was associated with the records storage and retrieval process.
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Patient records are stored in hard copy form for behavioral health, emergency room visits, same day surgeries, and inpatient admissions for the Rocky Mountain Surgery Center, and are stored for ten years in an offsite storage location. Medical records that are stored in digital form are kept online starting as recently as May 2010, making them a far more recent addition to the process. The record retention policy for the facility is that anything hard copy is maintained for ten years at the offsite storage location, while online medical records currently have no storage limitations due to the fact that such data is held in secure online servers complete with backups, taking up far less space than the traditional, hard copy approach to medical records storage and retrieval. Patient record processing and the maintenance of health information is completed on a department by department basis, though due to the fact that all departments are interrelated, to a degree, there is a measure of overlap that ensures that all are able to work together with ease.
Patient health records and medical data do have certain security measures in place, in order to ensure the confidentiality of patient medical data. Within the organization, each individual has their own set of permissions, or access level for those documents not stored online, and only those who have the necessity of accessing patient medical data are able to do so, either as a result of need for a case or as a result of their job description’s parameters. All medical records and associated health documentation is maintained under HIPPA standards and patient authorization forms must be filled out properly in order to ensure that patient data may be released to any individual outside of the medical facility.
The patient charts contain the patient registration form, patient’s past medical history, their physical examination results, results of any laboratory or other tests ordered, any records obtained from previous medical facilities, the diagnosis and treatment plan for the patient, all orders and medications prescribed, any operative reports, follow up visits, or documentation on telephone calls made, all informed consent forms, all discharge forms, any correspondence with or about the patient, and any information received by fax. All of this information is contained within the patient’s chart in universal chart order, however the medical records stored and viewed online may be viewed in a different order, due to their online medium; all hard copies must be stored in universal chart order without exception.
During the course of my time at Portneuf Medical Center I observed the preparation and scanning of patient charts, chart analysis, the work process of the data integrity specialist, the manager of the department, the job of the coordinator, and medical coding. I was able to observe how they reviewed the charts, dictated information, and the process for the discharge review of a patient’s chart in order to ensure that all documentation necessary was present and that nothing was overlooked. I was able to view the medical technician’s job process from start to finish, addressing everything from the manner in which they dealt with customers or patients who have requested medical records, how the authorization process is confirmed, and how the medical records themselves are processed and mailed out to those individuals. During the course of my time at the medical center, I attended one hospital meeting and two phone conferences.
I felt that my time at the facility was not only highly valuable but highly informative as well. It allowed me to better understand the concepts that I had been studying and it presented all of the information in a practical context, allowing me to determine what may or may not become a potential future career path for me. I felt that my time spent learning about each of the different jobs was more effectively utilized than my time spent observing the phone conferences and the hospital meeting; however I do understand the necessity of understanding the full day to day scope of life within this department, of which the meetings were a necessary part. Though my time at the Portneuf Medical Center was limited, I fell as though this was a valuable experience for me.
- Health.usnews.com. (2014). Portneuf medical center. [online] Retrieved from: http://health.usnews.com/best-hospitals/area/id/portneuf-medical-center-6820005 [Accessed: 6 Mar 2014].
- Portmed.org. (2014). Treatments & conditions. [online] Retrieved from: http://www.portmed.org/health/treatments_conditions [Accessed: 6 Mar 2014].
