The Health Information Management Services staff will process routine requests for Medical Records. All charts physically removed from the Medical Record storage areas will be logged, e.g., using a computerized tracking system Only authorized UC__ workforce members may access Medical Records in accordance with Privacy Policy and Procedure No. ____, “Employee Access to Protected Health Information (“PHI”).” UC__ Workforce members (as defined in Policy No. ____) who access Medical Records for payment or healthcare operations are responsible to access only the amount of information in medical records which is necessary to complete job responsibilities.
A. Access to Medical Records for Treatment Purposes.
Healthcare providers who are directly involved in the care of the patient may access the full Medical Record in accordance with Policy No. ____.
B. Payment Purposes.
Authorized and designated UC__ workforce members may access the patient’s medical record for purposes of obtaining payment for services, including the following uses:
1. Coding and abstracting;
2. Billing including claims preparation, claims adjudication and substantiation of services;
3. Utilization Review; and
4. Third Party Payor Reviews (including Quality Improvement Organization reviews).
C. Healthcare Operations.
Patient medical records may be accessed for routine healthcare operation purposes, including, but not limited to:
1. Peer Review Committee activities;
2. Quality Management reviews including outcome and safety reviews;
3. Documentation reviews; and
4. Teaching.
D. Requests for Electronic Components of the Medical Record.
Personnel who access the electronic Medical Record are required to have a unique User ID and password, and access to information is limited according to the minimum necessary rule and managed by role, as approved by designated management personnel.
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