Health Information Management and Medical Records

01Purpose and scope

• This manual supports the course Health Information Management and Medical Records. It describes how the work is actually done in hospitals, clinics, and physician practices: how a patient record is opened, what goes into it, who may see it, how it is coded and released, and how long it is kept. It is meant as a reference for a working day rather than a theory text.
• The scope covers the legal health record and the designated record set, along with the paper and electronic systems that hold them. Health information management staff, coders, release of information clerks, privacy officers, and clinicians all share this work, and the manual explains each role's part. It does not cover clinical treatment decisions, detailed billing appeals, or vendor-specific software configuration.
• Rules differ by country, state, and facility policy. Where a statement depends on jurisdiction, check the current authoritative source, such as your state health department regulations and the federal rules that apply to your organization. This guidance does not replace qualified professional judgment, approved facility procedures, or required authorization from a privacy officer or legal counsel.

02Core principles

• The record should be accurate, complete, timely, and attributable. Every entry needs an author, a date and time, and a clear reason for any change. Corrections are made by amendment, never by erasing or overwriting the original text.
• Access follows the minimum necessary principle for most uses. Access by a care team member for treatment is different from a request by an insurer or an attorney, and each needs its own authority. Treat every document as protected health information from the moment it is created.
• Records serve several uses at once. Clinicians write notes for patient care, coders and analysts reuse the same documentation for payment and reporting, and researchers may request de-identified extracts. A deficient record affects all of those uses, so completeness matters well beyond the chart itself.
• Retention is a decision, not a default. Each record type has a retention period set by law and facility policy, and destruction must be documented and authorized before it happens.

03Planning and preparation

• Start with an inventory of record sources: the electronic health record, scanned paper, imaging systems, laboratory interfaces, and outside records received from other providers. Map which system is the source of truth for each document type. Many problems in this field begin when two systems both claim to hold the same note.
• Confirm the policy set before the first release or audit. You need the facility's definition of the designated record set, the release of information policy, the retention schedule, and the consent forms in use, along with the current federal and state rules that apply. Assign an owner to each policy and set your own review schedule.
• Prepare roles in writing. Name who approves releases, who handles amendments, who codes, and who escalates privacy incidents. Smaller sites often have one person covering two roles, which works only when the duties do not conflict. For example, the person who amends a record should not be the only person auditing that amendment.
• Decide on supporting tools early. You will need an electronic health record audit trail, a release of information tracking log, a coding encoder with current code sets, and a secure method for sending outgoing records. Tool choices shape the workflow, so document the configuration your team actually uses.

04Recommended workflow

1. 1
   : Identify the patient and confirm the encounter. Match name, date of birth, and medical record number before filing any document. Duplicate and overlaid charts are a frequent source of wrong-patient data, so a second identifier check is worth the few seconds it takes.
2. 2
   : Verify completeness at discharge or episode close. Check that the history and physical, consent forms, operative notes, medication reconciliation, and discharge summary are signed and dated. Incomplete items usually land in a deficiency queue, and the closing deadline should follow facility policy and the medical staff bylaws.
3. 3
   : Query for missing or unclear documentation. Send a compliant query to the physician that offers reasonable options, including other and clinically undetermined, without leading toward a particular reimbursement outcome. Record the query and the response in the query log as policy requires.
4. 4
   : Assign codes from the encounter documentation. Use the code sets in force for the date of service, such as ICD-10-CM for diagnoses and CPT or HCPCS where they apply. Code only what the provider documented, and keep coder notes separate from the legal record.
5. 5
   : Process requests for release of information. Verify the requester's identity and authority, confirm that a valid authorization exists or that a permitted exception applies, limit the release to the minimum necessary scope, and log the disclosure. Route psychotherapy notes, substance use disorder program records, HIV-related information, and minors' protected information through the separate rules that govern them.
6. 6
   : Handle amendments and corrections. A patient may request an amendment, which the provider reviews and may accept or deny with a written reason. Accepted corrections are added with a date, an author, and a reason, and the original entry stays visible in the audit trail.
7. 7
   : Retain, archive, or destroy according to schedule. Confirm that no legal hold or open request applies, then follow the documented destruction method. Keep the destruction log or certificate on file.

05Quality checks, risk controls and compliance

• Run routine audits of record completeness, timeliness of signatures, and coding accuracy against source documentation. Many departments have a second reviewer check a sample of charts each month, though sample size and frequency should match your volume and risk profile.
• Control access through role-based permissions and review audit trails for unusual patterns, such as staff opening charts of patients with no care relationship to them. Investigate suspected inappropriate access promptly and follow the breach assessment steps in your privacy policy.
• Compliance depends on jurisdiction. In the United States, the Health Insurance Portability and Accountability Act privacy and security rules govern many uses and disclosures, and state laws often add stricter requirements for sensitive categories. Check the current text from the federal agency that enforces these rules and from your state health or attorney general office. Decisions that involve clinical judgment, legal interpretation, or coding dispute should be escalated to qualified staff rather than decided by the records clerk.
• Coding compliance needs its own controls. Use only documentation the provider authored, avoid adding codes for reimbursement alone, and maintain a process for correcting claims when errors are found, including refunds where the rules require them.

06Collaboration and documentation

• Records work depends on clinicians, information technology staff, coders, legal counsel, and privacy officers. Set a standing meeting or message channel for deficiencies that cross departments, and agree in writing on who responds to each type of request.
• Keep procedures written, versioned, and easy to reach. A release of information procedure should show the verification steps, the template letters, any fee rules, and the escalation path. Update the procedure when a rule or system changes, and keep prior versions for reference.
• Document decisions as well as actions. When a request is denied or a query is answered, the log should show the reason. When a retention exception is granted, record who approved it and which case it covers.

07Measures and continuous improvement

• Track a small set of indicators: the share of charts complete at a set point after discharge, average days to close deficiencies, release of information turnaround time, the share of coded records passing audit, and the number of privacy incidents with time to assessment. Set targets from your own baseline, since published benchmarks vary by setting and should be verified before you rely on them.
• Review the indicators monthly with the records committee or an equivalent group. Look for patterns, such as one physician with consistently late signatures, a payer whose requests always need clarification, or a template that produces repeated queries.
• Trade-offs are real. Tighter query rules may slow discharge billing, and stricter release checks may lengthen turnaround. Smaller facilities may need to outsource coding or release work, which brings business associate agreements and ongoing oversight duties with it.

08Common mistakes and how to prevent them

• Editing a note directly instead of amending it. This breaks the audit trail and can create legal exposure. Prevent it by restricting edit rights on signed documents and training staff on the amendment path.
• Releasing records without verifying authority, often when a caller says they are a family member or an attorney. Require documented authority before any release, and use a callback to a number on file when identity is uncertain.
• Coding from a problem list or an earlier encounter rather than the current documentation. Prevent it with a coding policy that requires the source note to be cited for each code.
• Treating substance use disorder program records or psychotherapy notes like general chart documents. Prevent it by tagging these categories in the system and routing their requests through the separate rules that apply.
• Leaving deficiencies open until a chart is needed for an audit or a request. Prevent it with aging reports that escalate items at fixed intervals set by policy.

09Practical checklist

• Confirm the patient identity on every document before filing.
• Check completeness and signatures at discharge or episode close.
• Send compliant, non-leading queries and log the responses.
• Code only from current documentation using the code set in force on the date of service.
• Verify authority and scope before any release, and log every disclosure.
• Handle amendments by addition with date, author, and reason.
• Restrict edit rights on signed documents and review audit trails on a schedule.
• Apply separate rules to sensitive categories and check current jurisdictional requirements.
• Follow the retention schedule and document every destruction.
• Review indicators monthly and update procedures with version dates.

★Learning sources

• Micro Degree: Health Information Management and Medical Records
• Micro Degree: Healthcare Administration Practice
• Micro Degree: Physiotherapy Assistant Operations
• Micro Degree: Cardiac Care Support