Health Information Management (Medical Records)

(718) 963-7151 or (718) 963-7152

The Department of Health Information Management is responsible for maintaining the patient’s Medical Record/Health Information in an orderly, confidential, secure and organized manner, and assures the availability of the medical record to authorized individuals. The department facilitates the communication of important patient information to various individuals within and outside the facility.

The Health Information Management Department actively participates in the overall philosophy of Wyckoff Heights Medical Center coordinating the hospital aims and objectives of obtaining optimal performance, utilizing efficient and economical means and promoting employee satisfaction by:

Maintaining operational expenditures without sacrificing quality of output.

Providing services to other departments, physicians, patients insurance companies and other authorized third parties in a most prompt and professional fashion according to set guidelines of confidentiality.

Instilling within all employees responsibility efficient for worker traits which will be invaluable in any work environment.

Activating interest and inquisitiveness of employees so that they will have an informed understanding, and as many areas possible, of a procedure or method and its place in the entire operation.

Working constructively with the employees and developing positive avenues of communication to assuage any fears and misbelieve that might otherwise arise and to fortify and increase the Director’s managerial skills.

The department is staffed by a Director, Coding Managers, DRG Validator, Customer Service Manager, Analysts, Coders Scanning Personnel, Clerks and one full-time Transcriptionist.

The department operates in two shifts, i.e., 8-4 p.m., 4-12a.m.

Important Aspects of Care and Services

The important aspects of care pertaining to the Health Information Management

Department are as follows:

• Preservation of all medical records/Health Information according to New York State Law.
• Set guidelines to ensure the confidentiality, security and integrity of date/information by:
  
  1. Assuring that medical records documentation is entered by appropriate and authorized professionals.
  2. That only authorized individuals have the medical record available for their use.
  3. Establish and maintain control over all scanning, archiving, filing procedures and record storage.
• Establish and maintain a standard arrangement for properly centralizing all pertinent medical forms and patient information.

• Review the content of the medical record entries for inconsistencies and omissions which may signify that the medical record is inaccurate or incomplete.
• Insure accuracy and completeness of the medical record in a timely manner.
• Serve as the basis for coding diagnostic data for official morbidity and mortality statistics, various medical needs and financial reimbursement.
• Provide guidelines for clinical documentation corrections.
• Assist in the development of the medical record forms to meet the needs of the Hospital.
• Assist in the development of the forms and data to be utilized in the Hospital Electronic Record.
• Maintain a safe working environment for employees, including patients and/or their next of kin, a safe environment for the storage of the medical records.
• Assure that all dictations are completed and entered in Meditech as specifically required.
• Assists in the preparation of medical records according to legal requests including that a subpoena is properly served, and/or appropriate releases are completed by attorneys and other parties.
• Ensure that Health Information Management Personnel participate in Orientation and Annual In-services both hospital-wide and department specific.
• Additional aspects of care that are identified by the department through established departmental information pathways including, but not limited to staff meetings, discussions, patient/family satisfaction surveys, staff surveys, formal needs assessment, staff evaluations, educational forums.

Additional aspects of care identified by the organization through the organizations formal committee structures, as well as, inform communication channels that identify high priority functions, processes, treatment and activities for monitoring and improvements.

Medical Records

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