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Programs & services
Medical Record Services
About Us
Medical Record Services apply the ethical standards
of the American Health Information Management Association
during the performance of its duties and strives to:
- Demonstrate
behavior that reflects integrity, supports objectivity and
fosters trust in professional activities.
- Respect the dignity of each human being.
- Improve personal competence and quality of
services.
- Represent truthfully and accurately professional
credentials, education and experience.
- Refuse to participate in illegal or unethical
acts and to conceal the illegal, incompetent or unethical
acts of others.
- Protect the confidentiality of primary and
secondary health records as mandated by law, professional
standards and the employer's policies.
- Promote to others the tenets of confidentiality.
- Adhere
to pertinent laws and regulations while advocating changes
which serve the best interest of the public.
- Encourage appropriate use of health record
information and advocates policies and systems that advance
the management of health records and health information.
What is a Medical Record?
The medical record is the property of
the hospital. It is used to facilitate access and maintain
the medical information as it relates to the management
of patients, support services, federal, state and local
regulations.
The medical record reflects the thorough, accurate and
complete compilation of medical data as it relates to patient
care and treatment provided under the direction of the
medical staff at Nantucket Cottage Hospital.
The
Medical Record Serves to:
- Provide a means of communication between the physician(s)
and other professionals contributing to the patient’s care.
- Plan individual patient care.
- Furnish documentary evidence of the care and treatment
provided during the patient's illness for each hospital
encounter.
- Assist in protecting the health related and legal interests
of the patient, physician, and hospital.
- Provide clinical data for use in long range planning,
research and education.
- Measure, assess and analyze the quality of care provided
by the hospital and its medical staff.
- Justify financial expenses incurred by the hospital while
providing care and treatment.
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Requesting Your Medical Record
- Print out and complete the Medical
Release form.
- Mail the completed
form to:
Nantucket Cottage Hospital
Attention: Medical Record Services
57 Prospect Street,
Nantucket, MA 02554
- If you are going to fax the form you must
call the Medical Records office before
sending.
Requesting
"Highly Sensitive"
Medical Records
If
you wish to
request copies
of the hospital's records regarding
your care and treatment for medical
conditions of a highly sensitive nature (i.e. drug and/or
alcohol abuse; HIV testing/treatment; venereal disease;
mental illness; domestic violence, sexual assault and/or
abuse), authorize the release of highly confidential
information by completing the following steps:
- Print out and complete the form for
the release of highly
sensitive and confidential information.
- Circle
the word 'release' in order for the hospital to be able
to access your records to answer a request for record
copies.
- Print the patient's name and date
of birth on the first line of the form.
Print the patient's address & telephone
number with area code using lines 2 and 3. The request
may not be processed if the telephone number is not included.
- Complete the section "Covering
the period(s) of treatment.” Circle the type of care
you received, i.e. hospitalization/observation and
record the date of admission if discharged in the spaces
provided. Circle ER (Emergency Room) - SDC (Surgical
Day Care) - MP (Minor Procedure) and write the date
of service on the line provided.
- If the type
of information you are authorizing to be released.
For outpatient laboratory and radiology
test results, check off the type of information you are
requesting to be released and include the date of the
test on the line marked "Other (Specify)."
- Write the Name and complete address
of the person to receive the information.
- If you intend to pick the information up at the hospital, you will need to bring a photo ID with you. Copies of the information will not be released without proper ID.
- Record the reason that the information is to be released/purpose the information is to serve.
- Mail the completed
form to:
Nantucket Cottage Hospital
Attention: Medical Record Services
57 Prospect Street,
Nantucket, MA 02554
- If you are
going to fax the form you must call the Medical
Records office before sending.
If you have any questions regarding the completion of
this form, contact Medical Record Services.
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Record Retention
To ensure patient information is available for continued care,
peer review, quality improvement activities, committee review
and reimbursement, Medical Record Services will maintain
the hospital's medical records against loss, defacement,
tampering or use by unauthorized personnel in accordance
with the state mandated 30 year retention regulation - MGR,
chapter III, section 70c.
Primary and secondary medical records for five
current years are maintained in the Medical Record Services
permanent file section.
- All primary and secondary patient records
greater than 5 years are held in the locked basement storage
area.
- Destruction of primary and secondary medical
records occurs once the state mandated retention schedule
of 30 years has been achieved.
- Newborn and pediatric medical records retention
period is the age of majority plus 30 years.
Medical Records and Privacy Security
According to HIPPA and Massachusetts General
Law, Chapter III, a patient has the right to have all medical
record information kept confidential.
The medical record is the property of the hospital and
shall be maintained to serve the patient, medical staff,
other health care providers and the hospital in accordance
with legal, accrediting and regulatory agencies.The information it contains is directly related to the
patient and is to be held in the strictest confidence.
No information shall be released without proper written
authorization, except in circumstances permitted under
the chapter.
The hospital respects and protects the patient's right
to privacy and confidentiality. Employees understand that
they are entrusted with confidential information about
the hospital's patients and must not discuss any information
disclosed to them in the course of their duties.
Restricted access is to protect the patient's rights to
privacy and to maintain confidentiality. Secondary health data, such as billing records, indices,
and reports must also be kept confidential and are protected
under law.
Some sharing of health care data is mandatory
and regulated by law.
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