. Patients as well as the clinic staff will be made aware that the electronic medical record and the information contained within are to be held in
. A patient must give written permission for the release of medical information from their chart. A parent or legal guardian must supply this permission for a minor. The only exception to this is when records ore released from provider to-provider for continuing medical core for the patient.
B. Responsibility: At the PBHC, maintenance, accessibility and systematic organization of medical records will be the responsibility of the Serrano Medical Center.
C. Development of Medical Records:
. Each patient will hove on individual electronic medical record. . Clinic visit notes will be recorded within the patient electronic medical record
on the dote thot the visit tokes place.
. A Medical Assistant, CNA or LPN will record height, weight, blood pressure, pulse, temperature, respirations, drug allergies (including severity level and symptoms of allergic reaction) and Chief Complaints when appropriate.
. Assessment of each visit will include either o presumptive or definitive diagnosis. Each clinic visit alone will include the following: dote of exam, chief complaint, history, review of systems, medication list, problem list, laboratory or imaging orders and results if violable and appropriate, diagnosis and treatment plan, including new prescriptions, patient education and instructions and return appointment if needed.
D. Personals Data Base:
. Each patient will be required to complete o new patient registration packet prior to his or her first provider visit. The, patient shall be required to provide on updated registration annually or if any of the demographic or insurance information changes prior to that.
. lf o patient is o minor or unable to supply the necessary information, o parent or guardian will be required to provide the registration data. E. Obtaining Medical Records from Previous Medical Providers: lf deemed appropriate by the clinic medical provider, it may be necessary to obtain
information in the form of medical records from previous medical providers or health core clinics. The patient (or their guardian) will be asked to sign a medical records release of information form so thot the records con be requested.
F. Referrals: lf the medical provider deems it necessary that a patient undergo further testing, such as imaging, EKG, sleep study, etc. or if the patient needs to see o specialty doctor, o flog or electronic order will be sent to the Patient Services Representative to obtain proper authorization based on the patient's insurance requirements and to schedule the test for the patient. Refer to specific policies and procedures for referral initiation, process and tricking for more information.
G. Miscellaneous Procedures: , All electronic medical charts hove o flow sheet w all laboratories, immunization, injections, and various tests ore recorded.
. Upon completion of on office visit, on electronic order shall be submitted to the billing/coding deportment to submit electronic filing to insurance
. Payments shall be electronically recorded in patient's electronic billing account. This account shall provide on accounting of any payments towards
charges, contractual and/or bod debt write offs along with any balance due and payable by the patient.
H. Filing of Records:
. Outside reports, records, test results shall be digitally indexed or scanned and electronically filed within the patient's electronic medical record and routed to the primary care provider for review and final signature. Due to the electronic nature of the chart, medical records con never be
. Charts of patients who hove not been seen for five or more years may be changed to inactive status within the electronic medical record. However, if
the patient presents for core later, they con be returned to active status.
. Deceased patient charts shall be marked as deceased and be placed in inactive status. Review of Records: Every notation, record, office visit, prescription or entry in the electronic health record shall be electronically signed by the responsible party, that being the provider giving medical core, the primary care provider, or staff member responsible for the document, etc.