Medical Records Director: Issues and Challenges

Introduction

Medical records directors work in the medical records departments in hospitals, office of physicians, mental health facilities as well as long term care facilities. The main role of the position of a medical director is to ensure that the medical records are kept well in accordance with federal guidelines. Also, accord to the established policies and procedures of a medical institution and to be able to make sure that there is a complete medical record program that is well maintained. (Elizabeth & Bankert, 2006)

For one to be a medical director he or she should be able to make decisions that are independent also to be able to deal well with visitors, personnel, residents, the agencies in the government and also the general public. To be a medical director one must have a lot of courage too because one must work with ill people, the emotional upset, disabled ones and hostile people within the department. A person with effective communication skills is a major requirement for being a medical director. (John, 2006)

The medical records directors are the ones responsible for making and implementation of the administrative decisions which affects the medical records program directly. For the improvement of the program, the directors must have detailed knowledge and skills that will help them in the testing and making of the recommendations with regard to the medical records.

Thesis statement

With reference to the given questions, this research paper will carry out a research to find out the roles of medical records director, who they are, their job description and responsibilities. This paper will look at legal issues, health care ethics and the challenges that are being face in this kind of job, as well as the career path expectations for the future of the role of a medical records director.

Job description

Medical records directors are also known as Health Information Mangers and works at the medical records department of hospitals. The medical records director is mandated with the task of making sure that hospitals goals and targets are met through the establishment policies and procedures that will guarantee the quality of medical services offered to the patients. It is the role of the director to make sure that all the Health information Management practices being able to meet state standards and the joint commission. The director is the one that oversees the improvement of quality, hiring and supervision of all activities which include including record completion, transcription of data, coding, assignments, filing and storage, as well as recovery of medical records.

The medical records director reviews discharges and death records in the nursing units and abstract information from the records as required by insurance companies or medical care. To prepare accurate reports to the accounts office and have resident financial records obtained and well maintained is another major responsibility. It is the medical record director who will ensure that all the work areas are clean and also to be able to mail out health care provider orders for signature. The director works with the staff closely so as to enhance the smooth completion of the medical records and the director reports to the Chief Finance Officer.

The daily job duties of the Director are to be able to supervise, motivate and also evaluate all employees with regards to the policies of the department. It’s their responsibility to conduct interviews and to hire new staff and training of the new personnel. The directors should always be updated on the new technologies and be able to implement the new technology. It is also their responsibility to be able to authorize the expenditures for new equipments and supplies (Field, 2007).

To be a Medical records officer, there are some education requirements and some certifications. It requires one to earn a 4-year bachelors degree in Health Information Management, and one must have completed an approved accredited program in health information Management. One must have successfully completed the National Examination as a Registered Health Information Administration (RHIA) certification or Registered Health Information Technician (RHIT) certification with at least seven years’ experience in the field. A Case Management certification is desired.

Legal and regulatory issues and tasks

When one is hired as a director, confidentiality agreements are signed both by the director and personnel. One is instructed not to share passwords or discuss the patient information or to take any medical records from the hospital. The medical records directors need to have good knowledge of federal and state laws because the director needs to know these laws as all states do not have the same laws. The HIPAA privacy regulation deals with protection of access to Protected Health Information that is held by entities that are covered.

Due to the rising cost of medical care, implementation of federal legislation has been found to be very important in that it will help in the lowering of the cost of medical care. This will in turn translate to revenue generation from the record department. The hospitals are mandated with the task of making sure that they keep detailed information that is necessary in the different payment plans with regard to the legislation. This will enable the government to plan and disperse the necessary funds that will be necessary in the hospitals for the treatment of diseases and other procedures.

With regard to privacy, the concern records can be rated both electronically and manually. The Health Insurance Portability and Accountability Act (HIPAA) came up with rules for one to access any information, storage and also auditing. These standards have certain restrictions that need to be followed. The director must ensure that there is confidentiality so as to be able to make the patient to be able to feel free and discuss detailed information which will help the in diagnosing conditions and the patient will be able to be treated appropriately. The information should be kept confidential about the patient unless they are required by the law which is rare (Pozgar, 2012).

It is the legal and ethical duty of the hospital to maintain patient confidentiality. The court has always allowed cause for legal action when there is a breach of confidentiality when one reveals confidential medical information and with no proper authorization from the patient or state. (Francis, 2003) Computer systems have passwords that are confidential and only the director and few clerks can access these systems. With this kind of system, then the patients have their information well kept. The medical director always prepares medical records for court trials. When there are cases in court, and it involves some medical records then they are the ones that will prepare these medical records. The director swears to the authenticity of the records and to state that they were not meant for the court but usual business.

Are the ones who will monitor local, national and international trends in the delivery of health care? This will help to ensure that the healthcare is done in an up to date manner and the best way to be the best institution and offer good medical care. It’s also the role of the director to work hand in hand with risk management, the IT department and the HR work hard as possible to minimize the risk of privacy, as well as security breaches. This will enhance patient confidentiality in the organization. The director is the one who cooperates with the civil rights office, legal entities and the organization officers in investigations or any other compliance. Also, interprets regulations in the application and formation of facility policies.

There are different programs that govern the medical records department some of the programs are Content Management System (CMS) which allows the publication editing and content modification, The American Health Information Management Association (AHIMA) which provides the directors with the educational resources as well as programs, Health Insurance Portability and Accountability Act (HIPAA) is the one that protects the health insurance coverage for employees and their families. The federal and state government, American Medical Association (AMA) and the AOA main representative organization for osteopathic physicians in the United States who work closely with medical records, as well as AHA represents hospitals, healthcare networks and their patients and communities; HIPAA is this job. It is the responsibility of the HIM department to keep patient information, confidential and secure. It is also their responsibility to protect the patient from unauthorized disclosure as well as to let the patient know who is to access at their records.

Litigation response plan

The Medical Records department follows the AHIMA litigation response plan. This policy addresses the disclosure procedure that relates to the federal rules of the civil procedures; the records can be in paper and electronic data. It’s an organizational policy to be able to produce and give information and records in accordance to the law, the procedures in courts or agreements that are made during the process of litigation.

They ensure that they follow the key concepts and how these concepts do relate. Some of the major concepts are Legal EHR: used as evidence in litigation which involves workers compensation and malpractice. The litigators requesting electronic data are increasing day by day. The industry is trying to focus more on the electronic records management so as to ensure there is credible evidence during legal proceedings. The other concept is Enterprise content and records management with the records management they should be good ones with the proper principles, and the best way is to apply them electronically so as to enable new practices. The organization should be able to manage all the contents well. The last concept is e-discovery which is the electronic environment that has changed the way in which litigation is being handled, and the evidence needed. Litigations are quickly embracing electronic information thus the organization must be able to have a good litigation response plan (Litigation response plan, 2009).

Challenges that are Medical Records Director face

Missing medical records: There are times some medical records may be missing. Someone altered some of the information on a certain file or deleted the data. It will be so hard for one to be able to have accurate information when treating a patient or giving out some statistics. For instance if a patient is found to have a certain disease, the records will have to be updated in their next visit to the hospital. There will be missing medical history and as a result, inaccurate information (ASHRM, 2010).

Up to date technology: Medical records director always need up to date technology that keeps on changing each and every time. This is hard for because they keep on changing and some become so hard to initiate in the organization. Some employees will require going for training. Also, the change of paperwork to electronic energy, people went back to school to be able to get trained on the issues of new technology.

Hacking of systems: The systems have been hacked on several occasions. This has led to information of a patient being altered, some clinical systems being destroyed and others adding false information. This is a very challenging aspect too because the records may end up being useless because the information that was important was altered with.

Misuse of information by authorized users: There are at times the authorized users misuse the information by being able to disclose certain information in public or to some people without the consent of the patient. This has been hard because patients lose hope in the medical institution as they expect everything about them to be confidential. An example is when one is diagnosed with AIDS and one who can access system knows about it and shares with the public, this will really affect the patient.

Salary: The directors do a pretty good job despite the many responsibilities they have. However, most of the directors are not well paid according to their workload. They do so much and get a little money, yet they are the ones that hold the most vital information in the organization.

Facilities and shortage of funds: There are times that the directors need to execute one or two things, but they lack the facilities to be able to carry out a certain task because they do not have enough facilities. At other times, they lack funds to be able to carry out certain programs too.

Heavy workloads: The kind of work the medical records directors do is a lot. Many of them spend almost 80 percent of their time working and trying to figure out what best to do. They do a lot of work in the organization, and this affects the social life of directors as they become workaholics.

The electronic medical records have faced so many challenges because many people working with the records department do lack knowledge and skills as well as experience and this has been hard to complete certain projects or the information is inaccurate. Some organizations don’t invest much in the records department because they do not see how important it is, with little or no expertise in information technology and software projects.Companies may have advanced technology but the companies they work with for instance the insurance companies. This will then be hard to implement some practices because of the difference in technology. Many hospitals too have not yet complied with this kind of technology thus affecting the operations of the other hospitals.

Reporting relationships

The directors are in the middle and they connect one department to another. They are the ones who hold the information of the institution; it also works directly with doctors and insurance companies as well as patients. Reporting relationships are two internal which is within the organization and external which is outside the organization.

External: They work with physicians because of the billing department and the Information Systems department. They work with the admission department so as to be able to ensure that there is accurate information in the system. Outside the medical facility, the directors do work with vendors who offer transcription, coding services and agencies as well as the billing offices. Internal: They report to the chief information officer and chief financial officer and in some cases they report to the CEO (Cleverley, 2009).

Ethical dilemmas

Ethical decision making needs a lot of courage because the current healthcare environment has created many ethical perplexities. One has to be able to quickly and yet asses situations. Some of the ethical dilemmas are for instance an employee being able to access and share private information to the public about a patient. For instance one employee knowing that one of the staff members has a barren wife and discloses the information to the other staff members or members of the family. This affects the reputation of the organization and the patient hospital relationship.

The citations in the medical records do not support that which has been billed. The evidence proofs that the documentation were done in a fair way and this raise questions on its accuracy. The argument is should the directors allow the same practice to go continue with the same trend?

Physicians allow the signature stamp to be used by others to complete medical records. This is a violation of the medical rules and regulation on the staff. Even with timely completion that helps in the billing process the director is told to ignore. The director is confused on what to do.

When a surgeon dictates an operative report like requesting for the date of dictation be same as the one of surgery, the surgeon makes this ensure compliance with hospital policy. Say the report was dictated by the surgeon a week after the operation. The putting in of the actual date or complying with the request of the surgeon is a dilemma because the surgeon may make one get fired or create a conflict

When there are requests for proposals sent to vendors, some vendors offer gifts like equipments or resources that are needed by the organization. This is a conflict of interest, but again the organization is going to benefit. At times, the insurance companies may ask for patient information that is related to the removals of a certain appendix. The medical records have some confidential information about psychiatric disorder and abuse of alcohol. Should the patient be contacted before release of records or not and if not the company refuses to pay claims unless records are released? (Harman, 2006).

Career path expectations for medical records Directors

The directors working more closely with the legal and the risk management department since most of the roles of risk management fall under a medical records director. Having an organization to grow and many young people being able to step up and work within the group who will run it effectively and efficiently. Another career path expectation is gaining experience and earning additional industry certifications also moving to a larger organization where one’s responsibilities are increased, and this turns one into an expert.

Being able to work as a consultant for many different organizations is also a career path expectation for the director, boosts someone’s career.

To be able to give accurate information as possible and all the information being kept in details for future references, another one is being able to adopt the new technology as fast as possible. Also, to ensure that all the systems are secure and no information easily accessed by any unauthorized person.

To maintain an organized system is another career path expectation being able to have a system that will be reliable in the present as well as the future, anything that is organized is always of benefit. Quality is what is important and to be able to always deliver quality service and reliable information in the hospitals. To be able to have experience that will enable one to be able to satisfy the increase in demand for the medical health and all services in the industry.

To be able to maintain team relationships so as to pull all the efforts together so as to be able to boost the whole department’s performance as well as to participate in the strategy implementation team to have the best decisions implemented.

Conclusion

Medical Records Directors are very important people in the health care sector because whenever a patient receives healthcare records are maintained. These records include surgical interventions, treatment outcomes and medical observations. All the medical history is stored in one file technicians are the ones that have these records well organized and stored and are accurate. The patient’s initial medical charts are well completed, and there is regular communication between physicians and all healthcare professionals so as to be able to obtain any additional information. There is no hospital that can operate without records because without records then the hospital cannot run at all.

The medical record directors are the ones that carry all the confidential documents in the organization and for this reason; they act as the heart of an organisation. They spend most times in trying to make sure that all the medical records are well protected and systems are working as required. The hospital management may be able to use the information that has been stored in the medical records which will help in the diagnosis and the treating of the patients’ disease. In addition to that, the medical records will assist in case of any claims of insurance by the hospital and the patients.

On the other hand, the administrative staff will be able to use the information in the medical records to plan for the services and resources. The medical records will also assist in the evaluation of the quality of the medical services offered to the patients which is very important in any given hospital. In terms of the legal affairs, the medical records will be used in the provision of data that will be used in the protection of the patients’ legal rights and those of the medical staff. The medical records director will be the ones that will provide the actual data that is necessary for licensure.

To create a culture that will support the adoption of Electronic Media Recording in this case everything will be computerized and a an administration that is closed loop which will enable the key stakeholders to be able to understand the benefits of EMR.

References

ASHRM, A. S. (2010). Risk Management Handbook for Health Care Organizations: Student Edition. Oxford: Wiley Publishers.

Cleverley, W. O. (2009). Whom does a medical records director report to. In W. O. Cleverley, Handbook of Health Care Accounting and Finance, Volume 1 (p. 904). Burlington : Jones & Bartlett Learning.

Elizabeth A. & Bankert, R. J. (2006). Medical records director. In R. J. Elizabeth A. Bankert, Institutional Review Board: Management And Function (p. 27). Burlington: Jones & Bartlett Learning.

Field, S. (2007). Career Opportunities in Health Care. Ney York: Infobase publishing.

Francis, T. (2003). Spread of records stirs fears of privacy erosion. The Wall Street Journal, 3(6), 5-7.

Harman, L. B. (2006). Dilemas facing medical record director. In L. B. Harman, Ethical Challenges in the Management of Health Information (p. 4). Burlington: Jones & Bartlett Learning.

John, T. W. (2006). Qualities of medical records director. In T. W. John Gatrell, The Specialist Registrar and New Consultant Handbook (p. 49). Oxford: Radcliffe Publishing.

Litigation response plan. (2009). Web.

Pozgar, G. D. (2012). Legal and Ethical Issues for Health Professionals. Burlington: Jones & Bartlett.

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