Information is an important asset of THI, and to keep this asset securely managed we have the best health care professionals in the HIMS department who work with the best of their ability to generate the data of various clinical information of every individual patient carefully and prudently.
THI HIMS department collects, compiles, manages, protects and disseminates the health information pertaining to patients. The data within a Medical Record justifies the treatment administered/prescribed for the patient, satisfies legal requirements, maintains sufficient provider documentation and authentication as well as allows statistical reporting and improves patient care.
HIMS at Tabba Heart Institute ensures the following:
- Timely availability of patients information
- Release information to persons and corporate customers according to regulations
- Provide patient information services in a courteous and user-friendly manner
- Improve the quality of records
- Maintain comprehensive clinical information of all patients of Tabba Heart Institute
- Ensure the accuracy of patients Data / Information
- Provide an atmosphere for training and development for the staff of HIMS
HIMS Objectives at Tabba Heart Institute:
- Complete implementation of medical records files management system
- Ensure the timely availability of medical records and information
- Maintaining a cordial team atmosphere within the department
- Review and update incomplete records
- Follow universally accepted Uniform Hospital Discharge Data Set to have uniformity
- Monitor patient data/information quality on regular basis
- Focus on the professional development of our staff
HIMS – Record Keeping that matters
The HIMS team is responsible for carrying out the following services that are briefly mentioned below.
The HIMS department is committed to providing accurate, timely and useful health information to meet the needs of its internal and external customers.
Document Management and Scanning
Due to space limitations, inactive patient records are scanned after three years of non-use. All records are scanned in-house and like their paper counterparts are available at all times. Scanned records may be reviewed in medical records at any time. If a patient returns to the hospital for care at a later date a new paper record is created and copies of selected scanned documents renewed in the records.
Investigation Reports Filing
Investigation reports received from various departments will be filled by the HIMS personnel in the designated section of medical records.
After discharge activity HIMS department staff shall analyze the medical record to identify deficiencies in documentation and the incomplete record is referred to the Attending Physician for completion. Once the patient has been released the incomplete medical records shall be available within the HIMS department or can be provided to assigned physician in the office on request. HIMS personnel reanalysis the deficiency after the end of every month. All records must be completed within 30 days of patient discharge. As THI is a leading referral institution, the timely completion of medical records by physicians is essential for continuity of patient care.
Outpatient and Inpatient Coding
The HIMS coding personnel is responsible for assigning international disease codes to all inpatient and outpatient records. The indexing of diseases and procedures allows this section to service the extensive requests for retrospective reviews of patient medical records by researchers and others. HIMS coding personnel is also responsible for compiling and reporting the official hospital patient statistics. Numerous standard and special statistical reports can be produced by this database.
The foundation of the HIMS department is its record room. All completed medical records are stored in this area. The record room is staffed with trained HIMS personnel who can make the medical records available for patient care at all times. Medical Records may be requested by a computer, or by E-mail. Normal requests of records for patient care purposes can be responded to within thirty minutes.
The records of released patients are conveyed to HIMS office daily after discharge and promptly assembled and processed to minimize the disruption of their use by caregivers. All records are placed in a standard documenting order to facilitate their use and are carefully checked for “deficiencies”. Selected information is also gleaned from records at this point and entered into a computer database.
Release of Information
The HIMS reception remains open from 08:00 to 17:00 Monday to Saturday. Patient Medical Record Number Card / Payment receipt or any other identification is required before medical information is released. Copies of inpatient investigation are released after seven working days from the date of discharge. Death Certificates are issued after seven working days from the deceased date.
Review of Records
The department has a dedicated office to assist researchers and others who conduct retrospective reviews of patient medical records. HIMS personnel can assist researchers to identify specific subsets of patients based on diagnoses and procedures to meet their research needs. To initiate a review the researchers must submit an approved review of records form to HIMS Department. Requested records are normally pulled and made available within 24 hours and can be held for review for up to one week.
To assist physicians with their documentation requirements, transcription services are provided by the HIMS department. The Medical transcriptionist transcribes various types of reports including operative notes, discharge summaries; diagnostic reports reference letter and consultation reports.
Future Goals for the HIMS Department
Remote Access of Patient Medical Record
- Electronic Medical Records
- HIMS Internship training
- Computerized Death Certificate
- Bar Coded File Tracking system