ensures compliance with the Freedom of Information and Privacy Acts, and submits to the collection agent any monies received for copying records.
This division compiles and analyzes statistical data pertaining to the care and treatment of inpatients, maintains the Tumor Registry and cross-index of diseases and operations, prepares medical statistical reports as required for the hospital or from higher authority, assembles and files clinical records, maintains the archives of inpatient records, receives, reviews and codes inpatient charts, applies Joint Commission on Accreditation of Hospitals (JCAH) standards to medical records, and maintains inpatient chart control. Some large facilities have further divided the Medical Information Services Division into branches.
This branch receives, reviews, and codes inpatient records for entry to the inpatient data system, and analyzes inpatient charts to ensure compliancy with existing medical records requirements.
This branch coordinates the timely input of all inpatient entries and change documents to the inpatient data system and receives and reviews all output reports, maintains automated inpatient listings and makes changes as they occur, and maintains the listing of delinquent charts.
This branch establishes and maintains the efficient operation of a tumor registry, registers and follows patients with a diagnosis of malignancy, retrieves and analyzes registry data, and disseminates this data in accordance with current directives. Chart Control Branch This branch receives charts from the Medical Information Services Division, Coding and Analysis Branch, routes the charts appropriately for dictation, signature, or filing in archives, assists medical practitioners seeking charts on recently discharged patients, and matches the completed dictation with the inpatient chart.
This branch files, stores, and maintains inpatient medical records and other records as directed, sorts and destroys or retires records stored in the archives as directed, and removes from the files and makes available categories of charts under study by authorized staff personnel. See NAVMEDCOMINST 6150.1 series for proper clinical record maintenance. See SECNAVINST 5212.5 series for record disposal.
This division coordinates procedures for the completion of medical records, including narrative summaries, medical records, periodic physical examinations, and autopsy protocols and reports, formulates dictation procedures and requirements, maintains the word processing/transcription center, and operates the central dictation system. Some large facilities have further divided the Medical Records Processing Division into branches.
This branch receives dictation through the central dictation system and transcribes reports using the computerized word processing system. It also processes narrative summaries, medical board narratives, periodic examination narratives, autopsy protocols, and final reports.
This branch receives medical board narratives, coordinates completion and final preparation of the medical board and cover sheet, makes proper disposition of medical board reports, and interviews patients to ensure correct and complete information.
This division provides general administrative support services to the Navy hospitals outpatient clinics and maintains close liaison and coordination with the appropriate directorates.