Contents Index HIMS Services Release of Information Retention of Patient Records Frequently Asked Questions Contact Information Services Provided Release of Information The Release of Information (ROI) Section of HIMS is where all requests are processed based on the order they are received to ensure that the processing of requests are completed in accordance with federal regulations, policies and procedures. Services provided include: References My Health eVet US Department of Justice ** National Archives and Records Administration (NARA) ** Centers for Medicaid and Medicare Services ** American Health Information Management Association * Copy and release medical records to those with a legal right to the information. Request copies of medical records from outside agencies or other VA Medical Centers. Request medical records be transferred to other VA Medical Centers. Process requests for medical records by the Regional Office. Record Analysis and Transcription Support This service of the HIMS department includes coordination of transcription of dictated documents, monitoring of quality and timeliness of transcribed documents, ensuring proper filing of electronic documents, resolution of errors of transcribed documents, review of medical records for completeness, notifying clinicians of records to complete, and keeping statistics of incomplete records for Joint Commission purposes. This service performs the quantitative analysis on medical records to ensure that all components are present, accurate, timely, and will meet the established requirements and standards of Joint Commission and VHA This review must ensure that the medical record contains sufficient information to meet medical-legal requirements, to ensure continuity of patient care, and to support education and research needs. File Room A Consolidated Health Record (CHR) is created and maintained for every individual that is treated or assessed within the facility. There is a medical record that documents the diagnosis and treatment of the patient, and there is an administrative record that pertains to the administrative aspects of the care of the patient. A terminal digit filing system will be used to file and retrieve patient records. There is also a Master Patient Index file that identifies all patients who have ever been admitted or treated by the health care facility. It is maintained on the VISTA system - Veterans Information System Technology Architecture. Consolidated Health Records are retained in the VA Health Care Facility until three years after the last episode of care. There after, records are inactivated and shipped to a Retirement Center and maintained for 75 years. The file room staff is responsible for ensuring that all information is filed in the patient record and the record is made available to the providers on request and for scheduled appointments. Coding Coding is a core function in Health Information Management. Qualified coders determine appropriate code assignment through a thorough review of medical record documentation. Codes are assigned to documented diagnoses and procedures for each episode of patient care using established classification systems. Accuracy of coding data impacts facility reimbursement, contributes to patient care decisions, and supports organization decision-making. HIMS Compliance Coordinator Role HIMS Compliance is responsible for identifying and providing educational needs for providers and coders based on auditing and monitoring findings. Communication of audit results to providers and care lines in order to initiate corrective action. Serve as documentation, regulatory, and coding resource to providers, MCCF, and coders. Communicate coding and educational needs in a concise effective manner. Development of educational programs for providers that will focus on their areas of specialty and individual needs. Development, implementation, and maintenance of the encounter form process throughout the VISN. Veteran Services

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