MHSC: Your Medical Records ‘Tell a Story’

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By Carrie Canestorp
Health Information Management Director
Memorial Hospital of Sweetwater County

Health Information Management at Memorial Hospital of Sweetwater County is an amazing team of 15 individuals that ensure your medical records are up-to-date, accurate, and secure.

We operate under the senior management of CFO Tami Love. We work closely with teams in the Revenue Cycle, Nursing Informatics, Quality, and Information Technology departments. We also work one on one with nurses and providers to assure the medical record contains all necessary components to comply with HIPAA (Health Insurance Portability and Accountability Act), The Joint Commission, and Centers for Medicare & Medicaid standards.  

Coders: My coding team makes certain the correct CPT and ICD-10 codes utilized for reimbursement route to our billing department in a timely manner. These codes “tell the story” of what occurred during your encounter here at MHSC.

Coders are responsible for reviewing all patient files for completion. They also are responsible for updating coding information in the hospital’s electronic medical record system, or Cerner, so the records include all relevant data, such as the reason the patient was admitted, type of illness, and breakdown of treatment prescribed and received.

Our coders are encouraged to become certified with either the American Academy of Professional Coders or the American Health Information Management Association.

Analysts: A medical records analyst position comes with its fair share of responsibilities.

My team of analysts confirms the medical record is complete, accurate, and up to date. They monitor the timeliness of provider documentation and audit all documents scanned in by other departments for accuracy. This ensures you get the best and most accurate medical care at our hospital and clinics.

HIPAA compliance is a large part of what we do each day. Keeping your medical records secure and only releasing them with the proper request and identification is of the utmost importance to us. This team is responsible for securely transferring your medical records to other physicians on your personal healthcare team or to your insurance for validation of services.

We confirm the correct release of information has been completed prior to any requests for records being fulfilled. We receive requests from disability agencies, and many legal requests for cases related to motor vehicle accidents, specialist care, and insurance audits. In addition, we file all birth certificates through Wyoming Vital Statistics, and we have two notary publics on staff. It gets quite busy here!

CDI RN: Our Clinical Documentation Integrity Registered Nurse is the physician’s partner, and collaborates with other multidisciplinary team members to ensure an accurate clinical picture of each inpatient admission. The CDI RN performs a concurrent review of each IP admission. She validates that the diagnoses are supported in the medical records based on diagnostic data available and will query physicians if a diagnosis is unclear or clinically unsupported.

HealtheLife Patient Portal: Did you know you can access your own medical record?

The Cerner HealtheLife Patient Portal makes this possible! It is easy to set up and simple to navigate.

Simply go to the MHSC website at sweetwatermemorial.com and click on the Patient Portal link at the top of the home page. This will take you to a page that describes the portal and its benefits in further detail. Click on the HEALTHELIFE link. If you have an email on file with the hospital, enter it here. If not, you can look up your account with your Social Security number.

I hope you have enjoyed this brief HIM overview. We encourage you to call our department at 307-352-8420 with any questions you may have.

For more on this, and all Memorial Hospital of Sweetwater County and its Specialty Clinics have to offer, go to sweetwatermemorial.com.

Carrie Canestorp is a Certified Professional Coder through the American Academy of Professional Coders and is working toward obtaining a Registered Health Information Administrator through Weber State University.


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