Health Information Management/Medical Records and Privacy

Location:

1st Floor, Main Hospital Building

Hours:

7 a.m. - 11:30 p.m.
Copies of records: 8 a.m. - 4:30 p.m.

Information:

• To obtain copies of records: 410.337.1169
• General Information/Receptionist: 410.337.1168
• Medical Transcription Manager: 410.337.1165
• Release of Information: 410.337.1169
• Director: 410.337.1163
• Fax: 410.337.1162

The Medical Record Department provides the following services:
• Retrieves records for patient care, research studies and audits.
• Compiles statistical and clinical data studies as they relate to case mix data, diagnoses and procedures.
• Releases medical information; responds to requests for information for patients, physicians, continuing health care, attorneys, insurance companies and subpoenas.
• Maintains the confidentiality of the information in the medical record and complies with all State and Federal laws related to privacy.
• Trains staff on privacy issues and conducts privacy rounds.
• Transcribes medical record documents. Physicians and Mid-level providers can call 410.337.1171 for dictation instructions.
• Prepares birth certificates and forwards them for filing at the Bureau of Vital Records. Processes death certificates. Call 410.337.1168 for information.
• Analyzes records of discharged patients for completeness according to federal and accreditation standards and the Rules and Regulations of the Medical Staff.
• Assigns the ICD and CPT codes for diagnoses and procedures for inpatient and outpatient medical records; sequences diagnoses and procedures to assure accurate DRG assignment; enters data into abstract system to create a clinical data base and provide information for billing.
• Assists physicians in completing their medical records through record retrieval and review of records for completion. Notifies physicians on a regular basis about incomplete medical records. Physicians can call 410.337.1173 to schedule a time to complete records or to gain assistance with electronic signature.