HIM 111 Release of Information Fundamentals
What do ROI Clerks do and who do they work with?
Works with HIM, record and process requests for patient records
Can Quick Disclosure releases be distinguished from HIM releases?
Yes because QD releases have a release type called point of care
Does Release to EpicCare Link require anything additional?
Yes, an additional Epic Application License
A new requester may not be recorded permanently in your database until this happens
You receive a few requests from them
Training is based as what?
Epic's Foundation System
What is Care Everywhere?
Epics framework for Health Information Exchange (HIE) that gets you from point A to B
Release restrictions are documented as these
FYI flags (available based off role and security)
What is a release type? What can it default?
A general reason for a request Priority, date needed, fee schedule (requests with the same RT have the same elements)
What is Legal Medical Record?
A group of medical records to make clinical decisions including health plan enrollment information
What can supervisors see in Workqueues?
A list of releases to assign the patient
Describe what a Foundation System is.
A patient populated with rich clinical data to help review its LMR (what we used was Paige Hailey Ingram)
What is an MRN?
A patients record number
Other Fee Tables include
Fees like priority shipping that indicate the amount charged and whether or not to apply tax
Release Restrictions are
Flags on a patients record placed from Patient FYI activity in Chart Central
What is a New Authorization used for?
For quick view and the determine that a valid authorization is on file. Also to see active authorizations
What is Save Letter used for?
For recording an electronic copy (can located in the Saved Letter Search)
Unique Batch Release fields
From to Date, Selected Data, Authorization, Output Format
When we BTG in basket messages are
Generated for recipients
What is Hyperspace?
Graphical user interface that holds Epic's applications
Releases posted are in what color?
Green
Which department is in charge of processing requests for patient records?
HIM
A release restriction warning appears to who and in what workflows?
HIM staff in an ROI workflow, clinicans in the QD workflow
When should we use the uncommon requester checkbox?
When there are many of the same name (insurance companies) and when they request patient records infrequently
What is the Site?
Where multiple release addresses are saved for a single requester (create by clicking New)
What is a Multiple Response SmartList?
Where you can select more than one choice. There are multiple reasons why the authorization is invalid
What the billing status is is based off of what?
Whether a bill is sent, payment is received, etc
Postage represents
A regular postage fee
Describe MyChart.
A shared personal health record (PHR) that gives patients controlled access to portions of the same medical record used by caregivers which reduces release requests
The 3 release restriction fields include
Contact, Flag Type, Comments Box
What are Smart Links?
Contained within smart texts, pull (link) information from the release into the record (this means that the data always represents the most recent documentation)
What is put into the Information Requested field?
Information for the release, there can be many choices that are selected from the electronic chart
What can be entered into the comments section?
Information that is released from a legacy system
Who may review a released patient record in RTI?
Inspectors, auditors, regulatory compliance bodies
What is the Orders level of Patient Information in the ES stored as and what are examples?
Is stored in Meds, Labs, Procedures in Chart Review. Examples include labs, imaging, meds, procedures
What is the Patient level of Patient Information in the Electronic section stored as and what are examples?
Is stored in Patient in Chart Review, examples include demographics, immunizations, allergies
What does Chart Search do?
It allows you to search menus and patients charts (Magnifying Glass Search) Known as smart search tool
Describe Print Preview.
It allows you to view records, determine the number of pages from an electronic release prior to release
What is Lucy? What does it do for patients?
It is a freestanding, personal, portable health care record that gives patients the freedom to control their electronic information from an Epic system
If prepayment is not required what happens to the invoice?
It is sent to the requester with requested records
What is a Single Response SmartList? What color background do they display with?
It might contain wildcards, SmartLists, SmartLinks, SmartTexts, display with a yellow background. Can only choose one choice
What does the Patient Disclosure Report do?
It tells who information is released to. To release to the PDR a release must have a status other than cancelled
Legal lockup does this for information. It also protects information from what?
Keeps it safe. Protects it from user access and alternation
HIM departments can charge for requests from whom? (4)
Law firms, insurance agencies, employers, external providers
Release to inspector provides what? Who uses it?
Limited secure access from workstation. Internal and external auditors
What does the Hyperspace User Toolbar do?
Lists frequent menu options (print, logout, releases)
Where is the Content section of the Electronic Section located? Describe this section.
Located in the middle of the screen. There is a different topic for each section and you can filter in from and to an area.
The Bill Outstanding Balances Workqueue does what?
Locates releases with outstanding balances
Personal Health Record uses what release methods?
Lucy, MyChart
A copy release does what?
Makes copy of the first release
Who had appropriate security in Legal Lockup
Managers and admin
Release restrictions are not used to do these three things
Mark private encounters, sensitive notes, or sensitive results
Requesters with poor payment history may require what type of payment?
Pre-payment
What does Lucy do request-wise?
Reduces requests in HIM by allowing patients to independently manage their PHR
Care Everywhere does what regarding release requests?
Reduces them allowing the immediate exchange of patient health information between organizations
The system is set up so that it searches what? Why does it do this?
Release requests within the last 30 days, to prevent duplicates
How do I get to expired authorizations?
Select options and check the expired check box
Once a payment is received what can we do to a bill?
Send it again
What does CareEverywhere do?
Share patient records between healthcare organizations on separate systems
My Chart settings in HIM System Definition do these two things
Show the number of days the release is available, determines max allowed release file size
What are SmartLists?
Single or multiple response pre-configured list of choices that are embedded into Smart Texts and Smart Phrases and always framed with braces
Smart Tools include (5 things)
Smart text, smart links, smart lists, smart phrase, wildcard
Total Fees are the sum of what?
Standard processing fees, media, other fees, postage and tax
What is the Encounters level of Patient Information in the ES stored as and what are examples?
Stored as Encounters, examples include office visit, hospital admission, ED, phone call (everything that happened start to finish)
What is the Notes level of Patient Information in the ES stored as and what are examples?
Stored in Notes in Chart Review, examples include H&P, discharge summary, OP note, consults
How do I find Today in a keyboard shortcut?
T and then tab
Snapshot of Legal Lockup happens quickly or takes time?
Takes time. Does not happen automatically when FYI flag created
What does Pre-Pay Only checkbox indicate?
That you should receive payment from a requester before releasing the records
With Care Everywhere HIM staff can view queries between organizations using what?
The Queries Report
What is the Release Address?
The address where released patient information is mailed or faxed
What is the Billing Address?
The address where the requesters bill is sent for release request
How can you preview a specific Content item?
The binoculars
Release requests are configured to record what? (3 things)
The date that the request is received, deadline it needs to be completed by, date it is complete
To verify that a release request is fulfilled, there needs to be a fulfilled release status. Describe this release status.
The final step in processing a request that indicates that the records are ready to be delivered to the requester
Where is On Hold located?
The navigator tool bar
Authorization tells whether or not...
The release was received and what type. They must be scanned at the individual release level
A batch release is when..
The same requester asking for the same information for multiple patients
What is the purpose?
The specific reason for a request that further defines the release type used for reporting and why it is released
What is the Hardcopy section used for in the Release Information Navigator?
Used to request charts by checking the box next to each chart that you need. Used for paper charts
How is information reviewed in Release to Inspector?
Using a pdf (log in to Hyperspace at your organization)
Y-1 keyboard shortcut means what?
1 year ago today
Two fields that determine how long the user has access to the released information in Release to Inspector are:
1. Default key expiration length days 2. Key cannot expire more than this many days in the future
What are the steps for organizing the clerks workflow in RIN? (4 steps)
1. Documenting the Request 2. Recording the authorization 3. Processing paper charts 4. Processing electronic charts
Ways to Post Payments include (4 ways)
1. Navigator: click to receive payment to document (billing section of navigator) 2. Workqueues: lots of checks, different requesters 3. Quick Post: Post payment in full to all of the releases in the list (adds everything and you can select individually) 4. Post payment activity: Can view the billing status for individual requests, edit releases, post payments that cover multiple releases
What are the three visible differences that the Unknown Patient Releases display with?
1. The patient name displayed in the header is highlighted yellow 2. The unknown patient section of the Release Navigator appears for you to record any known information about the patient 3. The Medical Records section of the Release Navigator is not available for unknown patient since the correct paper and electronic records cannot be identified
Quick Disclosure is what? What can it include?
A simplified workflow for releasing information where you only need to enter core pieces of data for patient disclosure (who received info, purpose, info released). It can include releases outside of HIM
Care Everywhere returns how many matches?
A single unique match
What is Smart Text?
A template to reduce documentation time (letter template to help write a letter)
What is a Workqueue?
A work list
Use Existing Button in Release Navigator within Release to Inspector allows what?
Access to multiple patients records via a single inspector key
In EpicCare link who may review released patient records
Affiliated providers
Selected data includes what?
All of the information you want to release, checking box for you
What does Lucy do?
Allows independent download and transfer of personal health records , helpful if patient visits multiple providers
What does the Assign Patient button do?
Allows you to assign the release request to the correct patient record
Release to Inspector does not require what?
An additional Epic application license
A contact is known as
An encounter, specify the contact that the flag applies
A request for patients records may include what?
An entire chart or only parts of it
What describes how Hyperspace moves?
At lightning speed, from one application to the next
With Care Everywhere, patients can do what regarding authorization?
Authorize the transfer of their information
In EpicCare Link, Epic determines what information is available by?
Basing it off of user login that can give a time frame and will expire
The batch release follows these steps
Batch Release -> Requester -> Choose Patients -> Create Releases
Parts of the Billing Section include (5 parts)
Billing status, media table, other fees table, postage, total fees
What does the Activity Toolbar contain?
Buttons such as Enter Queue and Report
How can requesters review information in EpicCare Link?
By logging in to EpicCare Link
How can HIM staff release information to requesters that are not in the database?
By using a blank generic requester (in Requester section of Release Information Navigator)
Shared Health Record uses what release method?
Care Everywhere
Who is BTG for?
Celebrity patients and sensitive encounters. BTG keeps close eye on what people do but does let them in to access records
Output formation is where you get to..
Choose whether the information should print, save to file, etc.
Point of Service includes what type of release? What release method is used in that type of release?
Clinician Release, QD
The comments box is used for what kind of comments in release restriction?
Comments about the release restriction, to display a warning
Describe Patient Summary Extracts.
Copies of releases are saved as these. Indicate needing an electronic copy of the release by checking the box "Save a copy of printed EMR" (covers organizations butt)
Describe what a copy release can do.
Copy values documented in one release request to create a new one (example: if twins request records sent)
Clerks need to do what to capture a patient record in Legal Lockup?
Create a release request and save a Patient Summary Extract
What does the Batch Release do to releases?
Creates them all at once
What word would be used to describe Epic software?
Customizable
After processing a request that requires billing, an ROI clerk does these steps
Determines if prepayment is required, sends an invoice to the requester if it is, and the request is marked to ensure that payment is received before the records are sent
What does Quick Disclosure do?
Documents patient records released outside of HIM
What do the Workspace Tabs do?
Each one you open generates a tab
What is documented in Release Information Navigator? What does it do?
Each request for patients records, it organizes the clerks workflow into specific steps
Save to file is used for
Easy transfer
What are the components of Hyperspace? (Six things)
Hyperspace title bar, Epic button, Workspace tabs, Hyperspace user toolbar, Chart search, Activity toolbar
Reasons that a patient may be unidentified
Incorrect spelling, name change, common name new to the org
What does an Unknown Patient Checkbox indicate?
Indicates that you cannot identify the patient
What does the Epic Button contain?
Menus (HIM and Reports)
What does an Electronic Medical Record contain?
More information than a paper chart
What does F2 do?
Move through a letter
What does Enter do?
Moves you to the next list
Release to My Chart sends a release directly to
MyChart
F8 to...
Navigate!
When communicating with new requesters this is what we create
New Letter
Does a password need to be generated by an individual?
No, it can be generated by the system.
Flags may apply to how many encounters?
One
Break the glass is what kind of security feature?
One that allows users to access restricted patient records
When releasing electronic records, the electronic section does this. What field is recorded here?
Organizes the patients record using buttons that mimic Chart Review activity. The Info Requested field is recorded here
Chart central provides what? What is it known as?
Patient based access to charts, deficiencies, release requests, etc. Known as Hub for HIM staff
Information that is released using the EpicCare Link method are called what?
Patient records available
Levels of patient information in the electronic section include: (4 things)
Patient, encounters, notes, orders
Who does Lucy "stay with"?
Patients wherever the receive care
Who can information be released to or who is it commonly released to?
Patients, parents, guardians, insurance companies, law enforcement, auditors, other providers
Integrated Alternatives include what two types of releases?
Personal health record, shared health record
Who can see the information contained in Lucy?
Physicians
With Legal Lockup, the person with appropriate security can
Place a Legal Review Patient FYI flag on the patient chart
What does the Output section contain?
Traditional release includes what release method?
Print or fax
Available Release methods can include (8 things)
Print or fax, save to file, release to inspector, EpicCare Link, Quick Disclosure, Release to My Chart, Lucy, Care Everywhere
What does Release of Information allow you to do?
Process release requests for patient charts in a time efficient manner
What does the Hyperspace Title Bar do?
Provides basic information, department you are logged into
Break the glass actions are
Recorded and they notify other users of their access
Releases not posted are in what color?
Red
What two elements in processing a release request work in conjunction?
Release type and purpose
Three Fields that determine Fee Schedule are what?
Release type, Chart Type, Requester
Information released is what in Release to Inspector?
Released patient records
A copy release is used for what?
Releasing 4 or fewer records to the same requester
If someone does not exist in the requester database what do you enter?
Requester Not in System
Who are common requesters?
Requesters that request often and are listed in the requester field
Electronic release includes what release methods?
Save to file, EpicCare Link, Inspector
Describe what Save to File does
Saves electronic patient records to file (in output section) and it is updated with a status of Fulfilled
A release template does what for ROI Clerks?
Saves them time by defaulting common information in the release request
What does EpicCare Link provide?
Secure online access to released patient records, an email is sent to the requester informing them about review as well
Describe Flag Type.
There are various ones seen by different users depending on security
From and to Date include what?
Time range for the release request to determine which patients encounters will be included in the release
Describe the Topic section in the Electronic Section. What does a red check indicate?
Titles running on the screen, can select information to release. That the information that was selected for release.
What do WIldcards (***) allow users to do? What must you do to the Wildcards before saving or sending?
To insert free text into documentation, must complete or delete all of the wildcards before saving or sending
What is Hyperspace used for? (Six things)
To register a patient, complete initial assessment, write a progress note, code the account, bill and post a payment, and release medical records
What is the spacebar used for?
To select a value on a list
What do workqueues do in billing?
Track the status of payments
Medical Records include what two types of releases
Traditional and Electronic
When is a New Letter used specifically?
When authorization is required but not provided this is sent to the requester saying that the request will not be processed until proper authorization is received.
The Media Table shows
Type of media and how much was provided to release the requested records (paper copies, DVD's, etc)
What are the five changes initiated by clicking Send Bill?
Update date billed, changes billing status, changes some fields to read only, invoice number, other options available
Once a PSE is generated HIM Staff can do what?
View the extract in Chart Review
Expiration date for one week from today keyboard shortcut?
W+1 and then tab
What does security level determine?
What a clerk can see on documents (access)
What does Epic determine regarding information in Release to Inspector?
What information is available upon login through the key
What is put into the Information Released field?
What is given, enter the information actually released
With ROI what can you choose to do? (4 things)
What to release, who to release to, formatting for release, billing for release
What does the type of Report depend on?
What type we want to release, the Information Requested values in the Release Section
What does a LMR say?
What we should release and what we should not release
What is Known Patient Checkbox?
What you click if the patient is known but not in the patient database
