1. Enter the request in the ROI database: information such as patient name, date of birth, health record number, name of requester, address of requester, telephone number of requester, purpose of the request, and specific health record information requested is entered in the computer.
2. Validity of the authorization is determined: The HIM professional will compare the authorization form signed by the patient with the facility's requirements for authorization to determine the validity of the authorization form. The facility's requirements are based on federal and state regulations. Certain types of information such as substance abuse treatment records, behavioral records, and HIV records require specific components be included in the authorization form per state (varies per state) and federal regulations. If the authorization is determined to be invalid, the request is returned to the requester with an explanation as to why the request has been returned. If valid to next step.
3. Verify the patient's identity: HIM professional must first verify that the patient has been a patient at the facility. Verification is done by comparing the information on the authorization with information in the master patient index (MPI). The patient's name, date of birth, social security number, address, and phone number are used to verify the identity of the patient whose record is requested. Patient's signature in the health record is compared with the patient's signature on the authorization for release of information form.
4. Process the request: the record is retrieved and the only information authorized for release is copied and released.
The Joint Commission (TJC) and state licensing bodies as well as Medicare Conditions of Participation (MCoP), National Committee for Quality Assurance (NCQA), American Accreditation Health Care Commission/Utilization Review Accreditation Commission, American Osteopathic Association, Commission on Accrediitation of Rehabilitation Facilities, Health Accreditation Program of the National League of Nursing, College of American Pathologists, American Association of Blood Banks, American College of Surgeons, Accreditation Association for Ambulatory Health Care, and American Medical Accreditation Program. The Joint Commission offers an accreditation program for hospitals and other healthcare orgs based on pre-established accreditation standards. -HIM manager would have enterprise or facility wide responsibility for HIM.
-Clinical Data Specialist perform data management functions in a variety of application areas including clinical coding, outcomes management, specialty registries, and research databases.
-Patient Information Coordinator: perform new service roles that help consumers manage their personal health information, including personal health history management, ROI, managed care services, and information resources.
-Data Quality Manager: perform functions involving formalized continuous quality improvement for data integrity throughout the enterprise
-Data Resource Admin: responsible for the net generation of records and data management using media such as the CPR, data repository, and electronic warehousing.
-Research and Decision Support Analyst: support senior management with information for decision making and strategy development.
- Security Officer - manage the security of all electronically maintained information, including the promulgation of security requirements, policies and privilege systems and performance audits.