hospital medical records department


Summary: Hospital department responsible for the creating, care, storage and retrieval of medical records. It also provides statistical information for the medical and administrative staff.

Top Publications

  1. Watzlaf V, Lares D. How HIM can ease the pain of medical errors. J AHIMA. 2002;73:37-44; quiz 45-6 pubmed
  2. Cummins R, Waddell J. Coding connections in revenue cycle management. J AHIMA. 2005;76:71-4; quiz 75-6 pubmed
  3. Coots C, Joerling K, Dougherty M, Edwards W, Foley M, Kohn D, et al. Enterprise content and record management for healthcare. J AHIMA. 2008;79:91-8 pubmed
  4. McBride J. Memorial Sloan-Kettering cures paperwork problems with document imaging. Comput Healthc. 1993;14:38, 40 pubmed
    ..The system now handles more than 2.7 million documents, including patient accounts and medical records. ..
  5. Hughes G. Simple steps to tracking disclosures. J AHIMA. 2002;73:68-70 pubmed
  6. Birnbaum C. Protecting verbal PHI: a plan. J AHIMA. 2003;74:65-6, 68 pubmed
  7. Kahn R. Beyond HIPAA: the complexities of electronic record management. J AHIMA. 2003;74:31-6; quiz 37-8 pubmed
    ..Learn how to protect your facility while preserving record integrity. ..
  8. Rothenberg R. The inescapable logic of institutional review boards. Ann Epidemiol. 2004;14:517-9 pubmed
  9. Dunn R. Turning production data into management tools. J AHIMA. 2002;73:60-2, 64, 66; quiz 67-8 pubmed
    ..Staring down another backlog in your HIM department? Use routine data collection activities to strengthen your case for additional staff, increased budget dollars, or an incentive program. ..

More Information


  1. Lipscomb C. Professional boundaries and medical records management. J Med Libr Assoc. 2003;91:393-6 pubmed
  2. Hughes G. Stop? Go? How to handle proposed amendments to the privacy rule. J AHIMA. 2002;73:24A-24C pubmed
  3. Amatayakul M, Lazarus S. The transactions extension: no reason to procrastinate. J AHIMA. 2002;73:16A-16C pubmed
  4. Wernick A. Connectivity, privacy, and liability. What medical professionals must consider. J AHIMA. 2007;78:64-5 pubmed
  5. Givens L, Phalen D, Kokoska M. Masters of patient indexing. Interview by Jessica Squazzo. J AHIMA. 2003;74:52-3 pubmed
  6. Paige L. Implementing a mainframe coding/abstracting system. Top Health Inf Manage. 1992;13:27-34 pubmed
    ..While thorough planning and organization will result in an efficient implementation, ongoing controls will ensure continued success and produce high quality results for any medical record system. ..
  7. Meyers S. Workforce. Coder shortage goes right to the bottom line. Trustee. 2004;57:30-1 pubmed
  8. Roohan P, Josberger R, Acar J, Dabir P, Feder H, Gagliano P. Validation of birth certificate data in New York State. J Community Health. 2003;28:335-46 pubmed
    ..Many of the data elements are reported accurately. However, caution should be used for data elements that are poorly reported. ..
  9. Squazzo J. Documentation coordinators put it all together. J AHIMA. 2003;74:38-9 pubmed
  10. Benavidez T, Friedman B. No place like home. Healthc Financ Manage. 2003;57:76-80 pubmed
    ..Decreases in contract and as-needed labor contributed to an operational cost savings of about $200,000 per year. The organization was able to fill all of its coding vacancies. ..
  11. Mallick S. Integration of leprosy control with primary health care. Lepr Rev. 2003;74:148-53 pubmed
  12. Burrington Brown J. Working smart. Risk assessment: doing more with less. J AHIMA. 2003;74:64-6 pubmed
  13. Malone M. Transcription vendors: how to make them your closest allies. J AHIMA. 2003;74:47-50 pubmed
    ..In the final installment of the Journal's four-part series on transcription, learn how to lay the foundation for a strong, enduring relationship with your transcription vendor. ..
  14. Fernandes L, Brandt M, Fletcher D, Grant K, Hatton L, Postal S, et al. Building an enterprise master person index. J AHIMA. 2004;75:56A-56D pubmed
  15. Hughes G. Practice brief. Defining the designated record set. J AHIMA. 2003;74:64A-64D pubmed
  16. Haugh R. Legal. E-disclosures. Hosp Health Netw. 2006;80:22, 24 pubmed
  17. Bryant G. Optical imaging systems--the future of medical record storage. Aust Med Rec J. 1993;23:78-81 pubmed
    ..The paper also discusses the much talked about legal side of optical imaging. Lastly the paper explains the future plans of Logan Hospital's Medical Record Storage System. ..
  18. Lorence D, Spink A, Jameson R. Assessing managed care market variation in reports of coding accuracy. Manag Care Q. 2002;10:15-25 pubmed
    ..Implications for managers and policymakers, related to comparative managed care data benchmarks, are reviewed. ..
  19. Wamwana E, Ndavi P, Gichangi P, Karanja J, Muia E, Jaldesa G. Quality of record keeping in the intrapartum period at the Provincial General Hospital, Kakamega, Kenya. East Afr Med J. 2007;84:16-23 pubmed
    ..It would be worthwhile to assess the sustainability of quality of intrapartum records and care a year or so after the SMDP ended. ..
  20. Carol R. From figures to facts: data quality managers emerge as knowledge leaders. J AHIMA. 2002;73:24-8, 2 pubmed
    ..This article explores how this position is emerging in the HIM field and becoming a key player in quality care. ..
  21. Upton M. The Royal Hobart Hospital digital medical records success story. Health Inf Manag. 2008;37:46-54 pubmed
    ..This article describes the processes involved in implementation of the electronic health record, including change management procedures and scanning of older paper-based records for inclusion in the new system. ..
  22. Clark J. A closer look at clinical pertinence standards. J AHIMA. 2002;73:91-2 pubmed
  23. Dimick C. Record limbo. Hybrid systems add burden and risk to data reporting. J AHIMA. 2008;79:28-32 pubmed
    ..Maintaining dual paper and electronic systems is often a necessity in the transition to digital record systems. The challenge in reporting data is keeping track of what data reside where. ..
  24. Hagland M. Revolution in progress: how technology is reshaping the coding world. J AHIMA. 2002;73:32-5 pubmed
  25. Sorg J, Swaney T. Stopping the record merry-go-round. New technology allows an organization to more efficiently manage patient records. Behav Healthc. 2008;28:40-2 pubmed
  26. Terranova G, Cortesi E, Briani S, Giannini R, Bartolomei M, Corsale I, et al. [Integrated medical records for surgical services: a new tool for a new hospital model]. Chir Ital. 2007;59:813-21 pubmed
    ..This paper presents the results of a long period of complex teamwork consisting in revising and sharing a new medical record model based on principles of professional integration and patient-centredness in health-care provision. ..
  27. Gomez S, Kelsey J, Glaser S, Lee M, Sidney S. Inconsistencies between self-reported ethnicity and ethnicity recorded in a health maintenance organization. Ann Epidemiol. 2005;15:71-9 pubmed
    ..Given the importance of ethnicity information, medical facilities should be encouraged to adopt policies toward collecting high quality data. ..
  28. Osborn C. DRG analysis reveals potential problems, trends. J AHIMA. 2001;72:78-84 pubmed
    ..Specific DRGs are frequently the targets of review if they are connected to errors. But documentation review alone to identify problems may not be sufficient. The author describes a strategy to review aggregate data for two tricky DRGs. ..
  29. Knaup P, Pilz J, Thalheimer M. Can temporary paper-based patient records sensibly complete an electronic patient record?. Stud Health Technol Inform. 2006;124:207-12 pubmed
    ..A temporary paper-based patient record in addition to the EPR is not an optimum procedure but feasible. The quality of the scanned, indexed and integrated documents in the EPR is high and the availability is sufficient. ..
  30. Glondys B. Practice Brief. Ensuring legibility of patient records. J AHIMA. 2003;74:64A-64D pubmed
  31. Laroche M, Vergnenegre A, Druet Cabanac M, Boutros Toni F, Salamon R, Preux P. [Quality of medical records in the "Medical Information System Program": application of the lot quality assurance sampling method]. Rev Epidemiol Sante Publique. 2002;50:433-9 pubmed
    ..This process could be applied to P.M.S.I., in which the search of quality is necessary because of the new cost model which includes secondary D.R.G. ..
  32. Brandner R, van der Haak M, Hartmann M, Haux R, Schmucker P. Electronic signature for medical documents--integration and evaluation of a public key infrastructure in hospitals. Methods Inf Med. 2002;41:321-30 pubmed
    ..Signature-oriented workflow and document management components are essential for user acceptance in routine clinical use. ..
  33. Hall T. Minimizing hybrid records. Tips for reducing paper documentation as new systems come online. J AHIMA. 2008;79:42-5 pubmed
    ..It can be tempting for providers to reach for paper, especially when things get hectic. Planning and support help keep the hybrid record from getting more hybrid than it has to be. ..
  34. Rollins G. New Joint Commission standards ahead. J AHIMA. 2008;79:58-9, 61-2 pubmed
  35. Kon K. File integration at Austin Health. Health Inf Manag. 2006;35:54-6 pubmed
  36. Bellenghi G, Coffey B, Fournier J, McDavid J. Release of information: are hospitals taking a hit?. Healthc Financ Manage. 2008;62:118-20, 122 pubmed
    ..The reduced fees may not cover expenses. If such legislation makes it difficult for outsourcing companies to make a profit from this service, hospitals ultimately could bear the expense and risk. ..
  37. Pena J, Santos B, Briones E, Corbacho B, Fernández Feijóo A, Exposito J. [Chemotherapy registry quality in Andalusian hospital pharmacy departments]. Farm Hosp. 2006;30:370-3 pubmed
    ..There is great variability regarding information systems for cytostatic use management, and a relevant shortage of patient data available for prescription use and adaptation studies. ..
  38. Oeffen G. Medical documentation and record management in Germany. J Am Med Rec Assoc. 1991;62:28-30 pubmed
    ..Her basic design is now the law of the land in Germany. Here she describes health record information practices in Germany. ..
  39. Kang H, Sirintrapun S, Nestler R, Parwani A. Experience with voice recognition in surgical pathology at a large academic multi-institutional center. Am J Clin Pathol. 2010;133:156-9 pubmed publisher
    ..The most helpful features of the software are templating, the seamless integration with APLIS, and the voice command creation tools. ..
  40. Mills Senn P. Staffing. Can home work work?. Hosp Health Netw. 2006;80:24 pubmed
  41. Piotrowski J. Rewriting the rules. Transcriptionists, radiologists hear call for changes. Mod Healthc. 2004;34:33 pubmed
  42. Yaggie E. Release of information: the basics. J AHIMA. 2001;72:56-61 pubmed
    ..Whether you're new to the HIM profession or a long-time expert, release of information presents perennial challenges--especially in light of HIPAA. This article brings you the basics and the latest updates. ..
  43. Li J, Morlet N, Semmens J, Gavin A, Ng J. Coding accuracy for endophthalmitis diagnosis and cataract procedures in Western Australia. The Endophthalmitis Population Study of Western Australia (EPSWA): second report. Ophthalmic Epidemiol. 2003;10:133-45 pubmed
    ..The use of external sources for case identification and case validation are two ways of ensuring data completeness/quality and validity of results. ..
  44. Haugh R. Workforce. Code blue. Hosp Health Netw. 2002;76:28, 30 pubmed
  45. Richey J. A new approach to chargemaster management. J AHIMA. 2001;72:51-5 pubmed
    ..Turnaround times were reduced and end users are happier. Here's how they did it. ..
  46. Rode D. Understanding HIPAA transactions and code sets. J AHIMA. 2001;72:26-32; quiz 33-4 pubmed
    ..What are the standard transactions and code sets? This article takes an in-depth look. ..
  47. Eisenhower C, McElwee K, Wargo C, Woodruff T. Data abstraction unplugged. Taking trauma registry to the point of care with wireless technology. J AHIMA. 2005;76:42-5 pubmed
  48. Walker D, Schmunk S, Summers L. Do birth certificate data accurately reflect the number of CNM-attended births? An exploratory study. J Midwifery Womens Health. 2004;49:443-8 pubmed
    ..Exploration of the inaccurately reported birth attendant data, implications for practice, and recommendations for accurately recording birth certificate data are discussed. ..
  49. Warner H. Finance. Code breakers. Health Serv J. 2004;114:44 pubmed
  50. Spolaore P, Murolo G, Sommavilla M. [Medical record management and risk management processes. State of the art and new normative guidelines about the organization and the management of the sanitary documentation in the National Health System or Hospital Trusts]. Ann Ig. 2003;15:805-15 pubmed
  51. Burton L. The life cycle of a project. How to plan for performance improvements. J AHIMA. 2003;74:34-6, 38, 40-4; quiz 47-8 pubmed
  52. Dimick C. HIM jobs of tomorrow. J AHIMA. 2008;79:26-30, 32, 34; quiz 37-8 pubmed
    ..Others are new roles, and some are possibilities. All are opportunities for HIM professionals to use their core competencies in new ways and move into positions that have not been thought of as career tracks for HIM. ..
  53. McCarthy T, Johnson M. How the EHR transforms the HIM department: two stories. Document imaging, workflow restructure department. J AHIMA. 2002;73:43-5 pubmed
    ..In this article, learn how the implementation of the EHR transformed two HIM departments--for the better. ..