Peninsula Regional Medical Center - Part of Peninusula Regional Health System

Key Responsibilities of Health Information

The Health Information Management (HIM) Department is involved in providing and processing patient records. These records contain patient information extending from pre-admission, through discharge, and afterward until that record is complete. The HIM Department receives all medical records the day after discharge, or date of service, in order to finalize processing the records in a timely fashion. This process includes:

  • Prepping, indexing and imaging all paper medical records

  • Analyzing the health record for completeness and accuracy

  • Quality Review of all imaged documents

  • Releasing patient information and protections assigned for closed-adoption, drug treatment, alcohol treatment, sexual and behavioral health issues

  • Coding for research, reimbursement and provider report cards.  (The coding personnel are responsible for abstracting diagnoses and procedures from medical records and assigning a numerical code to ensure accurate billing to a patient’s insurance company, and also for data collection purposes. Coding is instrumental in the scoring of physician report cards by organizations such as HealthGrades and Premier)

  • Transcribing and distribution of history and physicals, discharge summaries, consultations, operative notes, progress notes and other medical record reports from prior to admission through the completion of the Medical Center stay.  (Transcription coverage is provided 24 hours a day, 7 days a week to ensure all necessary documents are provided in a prompt and efficient manner for patient care)

  • Analyzing the active medical record to ensure all diagnoses have been accurately documented in the chart by the physicans of record (Registered nurses perform clinical documentation improvment during the patient's stay at the Medical Center)