Health Information Management maintains records for every person who has received treatment in the health center. All procedures, tests, surgeries, consultations, injections, and medication distribution in the hospital must be documented.
Health Information Management (HIM) is responsible for:
An electronic health record is a collection of electronic health information about individual patients. It is a record capable of being shared with other health care facilities. Such records may include a range of data in comprehensive or summary form, including demographics, medical history, medications, allergies, immunizations status, lab results, radiology images, vital signs, and other personal statistics. Its purpose is to be a complete record of patient encounters that allows quick access to the patient’s health information for use in all types of health settings. This can increase safety through evidence-based decision support, quality management, and outcomes reporting.
The HIM staff maintains a patient’s health information file while following strict HIPAA guidelines to protect patient privacy. Patients’ protected health information may be released only with written authorization from the patient when it is not for treatment purposes. These special authorizations are available when the completed authorization form (LINK to forms URL) is signed by the patient or the personal representative and mailed to the HIM department. The completed form may also be faxed to (308) 324-8311.
HIM clerks are responsible for daily maintaining the electronic health record, which includes analyzing both computer charting and converting the paper forms to electronic form by scanning and updating information.
When a baby is born at Lexington Regional Health Center, families provide the HIM staff with information, which is submitted electronically to the State of Nebraska Department of Vital Statistics.
To obtain a certified copy of a birth certificate from the state of Nebraska, please click here for more information. www.hhs.state.ne.us/ced/bicert.htm (url not in copy)
The HIM department also maintains the organization’s statistics including births, mortalities, surgeries, laboratory, and X-ray procedures, as well as other ancillary procedures.
The Health Information Management team is responsible for the utilization review and coding. This involves working with insurance companies and other third-party payers, such as Medicare and Medicaid, to determine what coverage is in force, verify approval on a patient’s length of stay, and enter billing codes to identify diagnoses and treatments.
Transcriptionists have the responsibility of transcribing dictation from various sources such as doctors, physical/occupational/speech therapists, and radiologists to compile data for reports into the electronic health record.
For Health Information questions, please call (308) 324-8309, Monday – Friday, 6:30 am – 5:00 pm.