Medical Transcription Services Company

MEDICAL RECORDS are the documents developed relating to patient care. in the hospital, they include all of the dictated reports, history physicals, discharge summaries, surgical procedures, x-rays, pathology, consulting reports, laboratory results, correspondence, virtually everything that was developed and/or printed for a patient. These records are all filed in the chart, which is stored in the Medical Records Department. Various providers use the chart, as well as people in the billing office. It is possible to do a lot of these functions now on a computer; with fully interactive capability from either the medical or nursing staff. Staff in the department pull charts for requesting providers, track which charts need dictation to complete, and advise providers of deficiencies as they become due or overdue for compliance to their records requirement relating to when the documents need to be dictated, transcribed and filed in the chart.

The department has a director, usually an RRA, Registered Records Administrator; MRA, Medical Records Administrator; or HRA, Health Records Administrator. Some hospitals have an ART, Associate Records Technician who is the administrator of the department. MRTs, Medical Record Technicians also work in this department.

Medical Records is the department you will typically work with in transcription. It receives the dictated and transcribed reports either electronically or as printed material, circulate for provider review, (either as a paper or an electronic process), correction, acceptance, and signature. Once those steps are completed, the hard copy is filed in the chart and copies are provided to the physician-provider who dictated the report.

Medical Offices, Clinics. The records are housed within the clinic (some have medical records departments) and/or doctor’s office in the patient’s chart. The process is similar to the hospital in that if a report is dictated, either hard copy or electronic file is transmitted to the clinic or doctor's office for printing, signature (correspondence) and mailing and/or filing. Copies of correspondence relating to patient referrals are kept in the patient’s chart. Chart notes are entered in a date sequence and are usually printed on a sticky back paper since they may only be a paragraph or two in length and thus A won’t consume a whole page in the chart which could grow voluminously if space were not a consideration. The chart note is then pasted in a date sequence in the chart.

Confidentiality/liability. Keeping information confidential is a very serious matter You will note that no patient names, identifying chart numbers, social security numbers, birth dates, physician names, hospital names are identified on the information on patient records you will review in this course. Everyone who reviews medical records is bound I by the need to keep information confidential. Though this certainly doesn’t work all of the time, you should be aware of the rules AND THE LIABILITY ISSUES. Read the law abstract in the next paragraph) from the Health Care Finance Administration and adopt the clear guidelines into the way you think about the information you will handle. As the Internet has (and continues to be) developed, new safeguards are in place, and more are anticipated keep abreast of those.

The Privacy Act of 1974 adopted into law mandates that federal information systems must protect the confidentiality of individually-identifiable data. Section 5 U.S.C. 552a(e) (10) of the Act is very clear; federal systems must: "...establish appropriate administrative, technical, and physical safeguards to insure the security and confidentiality of records and to protect against any anticipated threats or hazards to their security or integrity which could result in substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained." One of HCFA’s primary responsibilities is to assure the security of the Privacy Act protected and other sensitive information it collects, produces, and disseminates in the course of conducting its operations. HCFA views this responsibility as a covenant with its beneficiaries, personnel, and health care providers. This responsibility is also assumed by HCFA's contractors, State agencies acting as HCFA agents, other government organizations, as well as any entity that has been authorized access to HCFA information resources as a party to a Data Release Agreement with HCFA.

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