Novant Health Medical Records Department
- Introduction to Novant Health Medical Records Department
- What are medical records?
- Why are medical records important?
- The role of Novant Health Medical Records Department
- The services offered by Novant Health Medical Records Department
- How to request medical records from Novant Health Medical Records Department
- How long does it take to receive medical records from Novant Health Medical Records Department
- How to authorize someone else to access your medical records
- Privacy and security measures in place at Novant Health Medical Records Department
- FAQs about Novant Health Medical Records Department
Introduction to Novant Health Medical Records Department
Novant Health Medical Records Department is a crucial component of Novant Health, a not-for-profit healthcare system that serves communities across four states in the southeastern region of the United States. The Medical Records Department plays a pivotal role in maintaining accurate and complete records of patients' medical histories, diagnoses, treatments, and outcomes. The department is responsible for the creation, storage, retrieval, and sharing of medical records to support patient care, clinical research, education, legal and regulatory compliance, and other purposes.
What are medical records?
Medical records are documents that contain information about a patient's health status, medical history, diagnosis, treatment, and follow-up care. They include data from various sources, such as physician notes, laboratory results, imaging studies, medication lists, vaccination records, and discharge summaries. Medical records also encompass demographic and insurance information, consent forms, advance directives, and other legal documents. They may be in paper or electronic format, and they are subject to various laws and regulations that dictate their confidentiality, accessibility, and quality assurance.
Why are medical records important?
Medical records are essential for providing safe, effective, and coordinated healthcare. They serve several purposes:
- They enable healthcare providers to make informed decisions about diagnosis, treatment, and management of patients' health conditions.
- They facilitate communication and collaboration among healthcare team members, including physicians, nurses, pharmacists, therapists, and other professionals.
- They support quality improvement initiatives by tracking patient outcomes, identifying areas for improvement, and benchmarking against best practices.
- They ensure compliance with legal and regulatory requirements, such as HIPAA, HITECH, and state privacy laws.
- They enable patients to access their health information, understand their diagnoses and treatments, and participate in their care decisions.
- They provide a basis for clinical research, public health surveillance, and population health management.
The role of Novant Health Medical Records Department
The Novant Health Medical Records Department is responsible for managing the medical records of patients who receive care at Novant Health facilities. The department ensures that medical records are complete, accurate, and accessible to authorized users while maintaining their confidentiality and privacy. The department also supports the healthcare providers and patients by providing timely and efficient access to medical records for clinical, administrative, legal, and personal purposes.
The services offered by Novant Health Medical Records Department
The Novant Health Medical Records Department offers several services to patients and healthcare providers:
- Release of Information (ROI): The department processes requests for copies of medical records from patients, authorized representatives, healthcare providers, insurance companies, attorneys, and other entities. Requests can be made online, by mail, fax, or in person. The department verifies the identity and authority of the requester, retrieves the requested records, and prepares them in accordance with applicable laws and regulations. Fees may apply, depending on the type and volume of records requested.
- EMR (Electronic Medical Record) Support: The department provides technical support and training for healthcare providers who use Novant Health's electronic medical record system. The department assists with user accounts, passwords, access privileges, troubleshooting, customization, and upgrades. The department also monitors the quality and integrity of the electronic medical records to ensure compliance with regulatory standards.
- Legal and Regulatory Compliance: The department maintains policies and procedures to comply with federal and state laws and regulations governing medical records, such as HIPAA, HITECH, and state privacy laws. The department also responds to subpoenas, court orders, and other legal requests for medical records, in coordination with Novant Health's legal counsel.
- Patient Education: The department provides educational materials and resources to patients and their families about how to access, understand, and manage their medical records. The department also assists patients with completing advance directives, consent forms, and other legal documents related to their healthcare.
How to request medical records from Novant Health Medical Records Department
To request copies of medical records from Novant Health Medical Records Department, patients or their authorized representatives can follow these steps:
- Visit the Novant Health website or go to the Medical Records Department in person.
- Fill out the Release of Information (ROI) form, providing the patient's name, date of birth, social security number, contact information, and the type of records requested.
- Attach a copy of a government-issued photo ID and any legal documentation authorizing the request if applicable.
- Specify the format and delivery method of the records, such as paper or electronic, mail or email.
- Pay any applicable fees, if required.
- Submit the completed form and payment to the Medical Records Department online, by mail, fax, or in person.
How long does it take to receive medical records from Novant Health Medical Records Department
The processing time for requests for medical records from Novant Health Medical Records Department depends on several factors, such as the volume and complexity of the records requested, the availability of the records, and the type of requestor. Typically, requests for copies of medical records are processed within 15 business days from the receipt of the completed ROI form and payment. However, some requests may take longer if additional documentation or verification is required. Patients can contact the Medical Records Department to check on the status of their request and receive updates on any delays or issues.
How to authorize someone else to access your medical records
Patient privacy and confidentiality are paramount in the management of medical records. Therefore, patients who wish to authorize someone else to access their medical records must provide explicit consent and follow the applicable legal and regulatory requirements. The Novant Health Medical Records Department offers several options for authorizing access to medical records:
- Complete a Release of Information (ROI) form that specifies the name and contact information of the authorized representative and the scope of the authorization. The form must be signed and dated by the patient or their legal guardian.
- Provide verbal consent over the phone or in person to the Medical Records Department, accompanied by identity verification.
- Use Novant Health's online portal, MyChart, to grant access to selected medical records to designated individuals, such as family members or caregivers. MyChart requires registration and authentication by the patient.
Privacy and security measures in place at Novant Health Medical Records Department
The Novant Health Medical Records Department is committed to protecting the privacy and security of patients' medical records. The department follows strict policies and procedures to ensure compliance with federal and state laws and regulations governing medical records, such as HIPAA, HITECH, and state privacy laws. Some of the measures in place include:
- Access controls: The department restricts access to medical records to authorized personnel who have a legitimate need to know for patient care or other approved purposes. Access is granted based on role-based permissions, user authentication, and monitoring of activity logs.
- Data encryption: The department uses encryption technologies to protect the confidentiality and integrity of electronic medical records during transmission and storage. Encryption keys are managed securely and in accordance with industry standards.
- Audit trails: The department maintains audit trails of all activities related to medical records, including access, modification, disclosure, and destruction. Audit logs are monitored regularly to detect and prevent unauthorized or suspicious activities.
- Physical safeguards: The department implements physical measures to protect paper records, such as locked cabinets, restricted access, and secure transportation. The department also ensures that electronic devices containing medical records are stored in secure locations and disposed of properly.
- Training and awareness: The department provides regular training and awareness programs to its staff and healthcare providers to raise awareness of privacy and security risks associated with medical records and to promote best practices for safeguarding them.
FAQs about Novant Health Medical Records Department
Q: Can I request medical records for someone else?
A: Yes, you can request medical records for someone else if you have legal authorization, such as power of attorney or guardianship, or if you are the authorized representative of the patient, such as a parent, spouse, or legal agent. You must provide documentation of your authority and follow the same procedures for requesting medical records as the patient would.
Q: How much does it cost to request medical records from Novant Health Medical Records Department?
A: The fees for requesting medical records from Novant Health Medical Records Department vary depending on the type and volume of records requested and the method of delivery. The department follows the fee schedule established by the State of North Carolina for paper records and the federal regulations for electronic records. Patients can contact the department or check the website for the current fee schedule.
Q: Can I receive my medical records in electronic format?
A: Yes, you can receive your medical records in electronic format if they are available in that format and if you provide a secure email address or a USB drive to store the records. However, you must sign a consent form acknowledging the risks and benefits of receiving electronic records and agreeing to protect their confidentiality and integrity.
Q: How long does Novant Health Medical Records Department keep medical records?
A: Novant Health Medical Records Department follows the retention schedule established by federal and state laws and regulations governing medical records. Generally, adult patient records are kept for at least 10 years after the last date of service, while pediatric patient records are kept until the patient reaches age 21 or 10 years after the last date of service, whichever is longer. Some records, such as psychiatric or substance abuse treatment records, may be kept for a longer period.
Q: Can I correct errors in my medical records?
A: Yes, you can request corrections or amendments to your medical records if you believe that they contain errors or incomplete information. You must submit a written request to the Novant Health Medical Records Department, specifying the nature of the error and providing supporting documentation, such as a physician's note or lab report. The department will review the request and notify you of its decision within 60 days. If the request is granted, the department will make the necessary changes and inform all parties who received the original records. If the request is denied, you have the right to file a complaint with the Department of Health and Human Services.
Frequently Asked Questions About Novant Health Medical Records Department
What is the Novant Health Medical Records Department?
The Novant Health Medical Records Department is responsible for maintaining and managing all patient medical records for Novant Health facilities.
How can I request a copy of my medical records?
You can request a copy of your medical records by filling out a Novant Health Authorization for Release of Protected Health Information form and submitting it to the Medical Records Department. You can also request your records online through MyChart.
How long does it take to receive a copy of my medical records?
It can take up to 30 days to receive a copy of your medical records. However, urgent requests can be expedited for a fee.
Is there a fee for requesting a copy of my medical records?
Yes, there may be a fee for requesting a copy of your medical records. The exact fee will depend on the number of pages requested and the format in which you want to receive them.
