The Health Information Management Services team, historically known as “Medical Records” and primarily focused on the handling of the patient’s paper chart, now has the responsibility for managing all of the patient health information (PHI) that is captured within the electronic systems and using any paper forms during a patient’s visit.

UM Staff use HIMS supported applications to:

• Manage the filing and distribution of paper medical records
• Track and release of PHI upon appropriate request
• Summarize (abstract) patient data, then categorize the visit using the ICD9 (International Classification of Diseases v9) and DRG (Diagnosis-Related Group) codes which are then submitted to Medicare, Medicaid and other insurers for reimbursement.
• Scan paper documentation for electronic archive of the patient data/form
• Record patient assessments and treatment plans using dictation and transcription
• Request validation and sign-off of transcribed documentation using electronic signature authentication

• HIMS safeguards for the legal medical record and distribution of patient health information (PHI) upon formal requests with patient authorization or per HIPAA regulations.
• Efficient processes for the day-to-day operations of paper patient record retrieval, filing and archive
• Efficient processes for the scanning of paper documents into an electronic format within 24 hours of the patient’s care delivery
• Efficient processes for the transcribing of dictated patient reports
• Prior to billing, the HIM professionals summarize and code the data in accordance with payer requirements
• Upon patient discharge, our HIM professionals audit the record to ensure that all components are completed

• Collaborative projects with the UM clinicians and staff to select, design, develop, test and “go-live” with the applications to support the activities described above
• Support and management of the personnel scanning documents into Cane Care (UM)
• Transcription systems used by internal and external transcription resources
• Responsibility of ensuring record completion according to Medical Staff Bylaws and JCAHO guidelines
• Record retention (ensuring that PHI is retained according to hospital policy and state guidelines)
• Knowledge on HIPAA guidelines pertinent to release of information.
• Knowledge of ICD-9 CM and CPT-4 coding guidelines. This is essential for appropriate reimbursement for all inpatient and outpatient billing.
• Expertise for the following applications:
  • Voice Wave (DVI)
  • ChartScript (SoftMed)
  • Electronic Signature Authentication ESA (SoftMed)
  • Encoder System (3M)

• Registered Health Information Administrator (RHIA)
• Registered Health Information Technician (RHIT) eligible
• CPHIT (Certified Professionals in Health Information Technology)
• CPEHR (Certified Professionals in Electronic Health Records)
• Graduate degrees in healthcare management and Health Services Administration

• UMHC and ABLEH have their own respective HIM Departments which provide a variety of HIM functions including (record storage and retention, chart pulls for Quality reviews and audits, assembly and analysis of record, release of information functions, and ICD-9 and CPT-4 coding (this includes both inpatient and outpatient).
• UMCET maintains the web portal archive and the ability for users to request on demand EMR ready bar-coded forms
  • Standard documentation forms for the patient chart
  • Access EMR bar-coded forms while logged on to the medical domain at http:/forms.
• Our EHR Documentation Technologies team members manage the daily process of scanning patient charts to capture, index, and populate CaneCare, our hybrid electronic medical record.