Logging, Tracking and Verifying the Request |
| 1. | Receive medical record request. |
| 2. | Log request into tracking system (Important for accounting of disclosures regulations under HIPAA; this is also imperative to monitoring the status of time-sensitive requests such as RAC, Meaningful Use, or other audit related requests). |
| 3. | Validate request by identifying the patient as a recipient of care at the facility and investigate the HIPAA compliance of the patient authorization to release records. |
| 4. | If the request is not valid, notify the requestor. |
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Retrieving Patient Information |
| 5. | If valid, determine the correct medical record number. |
| 6. | Retrieve medical record (paper, electronic or microfilm), if onsite. |
| 7. | If offsite, retrieve medical record through proper channels. |
| 8. | If microfilm, print record. |
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Releasing Only Authorized Information |
| 9. | Confirm that medical record is complete. |
| 10. | Authenticate patient signature. |
| 11. | Match the medical record request with the medical record. |
| 12. | Make initial assessment if medical record request can be processed. |
| 13. | If the request cannot be processed, notify the requestor. |
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Safeguarding Sensitive Information |
| 14. | Locate exact information that has been requested and review and examine each page of the record for confidential and legally protected information. |
| 15. | Continue next level of evaluation of the request and determine if it can be released. |
| 16. | If confidential or legally protected information cannot be released, notify the requestor. |
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Monitoring, Completing and Invoicing Request |
| 17. | Identify documents for digital capture. |
| 18. | If working with a paper chart or microfilm, disassemble and digitally capture the pages with the requested and authorized information or designate pages within the electronic health record and package with request. |
| 19. | Verify patient identification on every page. |
| 20. | Review request and chosen pages from the medical record to determine accuracy of the information. |
| 21. | Reassemble the paper chart. |
| 22. | Update request status log. |
| 23. | Prepare documents for distribution (mail, e-delivery). |
| 24. | Create invoice for service. |
| 25. | Set up accounts receivable file if no payment was received with request. |
| 26. | Record payments, if received. |
| 27. | Send requested documents to requestor. |
| 28. | Return records to original location or sign out of electronic health record. |
| 29. | Perform ongoing customer service related to the request. |
| 30. | Track outstanding invoices and perform collection efforts as needed. |
| 31. | Monitor status and completion of pending requests and expedite time-sensitive items such as RAC, other audit related, or Meaningful Use requests. |
| 32. | Close out request in tracking system when payment is received. |