Health Information Management Professional

The HIM Professional is responsible for ensuring the delivery of complete and accurate clinical records in full compliance with all applicable provincial legislation; for monitoring the Mental Health Act forms; for health record information management process which includes liaising directly with the clinical staff to facilitate this mandate. Ensures the confidentiality of patient information is respected and maintained in accordance with all ethical and legal requirements.

Duties:

Accountability #1: Quantitative Analysis of Clinical Records for Completeness

• Performs a quantitative analysis of the clinical record for the completeness, accuracy, quality, validity and reliability and ensures the information meets hospital accreditation standards, statutory and legal requirements.
• Confirms accuracy of outpatient chart openings and re-openings as completed by the secretarial staff. Flags errors for correction and ensures final resolution.
• Provides assistance and instructions to secretarial pool with inquiries on Meditech applications.
• Inputs/edits chart deficiencies in the Meditech chart deficiency tracking system.
• Maintains Meditech Borrower files according to Program staffing.
• Monitors physician and discipline compliance with chart deficiency policy.
• Reports physician non-compliance to Director of Clinical Records and to the Clinical Directors.
• Reports discipline non-compliance to Director of Clinical Records, and Professional Practice Directors
• Maintains and dispatches deficiency letters of warning/suspension.
• Assists clinical staff with any inquiries / concerns regarding the chart deficiency process
• Assists Physicians and Allied Health Staff in the completion of their deficiencies.
• Office of Consent and Capacity Board – arranges and coordinates hearings resulting from the applications submitted by patients with regard to their involuntary status or incapacities to manage their estate or treatment decisions
• Assists Patient Advocate, Rights Advisor and hospital staff – with regard to the particular matter subject to a Review Board hearing

Accountability #2: Completion of RAI tool

• Resolves/clarifies diagnoses with conflicting, missing or unclear information by consulting with the physician.
• Assists Allied Health Professionals and Physicians with completion of data in RAI tool.
• Retrieves selected data elements to complete the medical information on the RAI tool.

Accountability #3: Monitoring of Mental Health Act Forms

• Reviews Mental Health Act forms pertaining to changes of patients’ legal status, for validity and correct calculation of time, identifying discrepancies and following up with clinical staff, including providing copies to Rights Advisor, and preparing forms for scanning to EHR
• Prepares and distribute monthly a report of upcoming expired forms to psychiatrists
• Enters data in Registration Legal Status screen and generates related reports for distribution to psychiatrists
• Communicates with the office of the Public Guardian and Trustee to ensure that declarations regarding financial capacity are processed efficiently and correctly
• Monitors requests for clozapine funding by keeping a log of all requests, prepares letters for the interim clozapine coordinator to approve or deny funding; faxes all approved or denied funding letters to the requesting physician and to the finance department and files each request

Accountability #4: Registration

• Entering and updating inpatient and outpatient data onto Admissions/Discharges/Transfers (ADT) System.
• Prints inactive case lists, on a quarterly basis to discharge outpatient admissions.
• Completes final analysis of the clinical record.
• Assigns deficiencies to appropriate physician and other clinicians to complete closure procedure.
• Notifies staff physicians’ secretaries to book time and close their charts.
• Ensures physician has completed outpatient discharge order before discharging outpatient account.
• Discharges account in registration module, once charts are closed and complete with final diagnosis, by entering date of discharge and disposition.

Accountability #5: Release of patient information

• Accepts processes and responds to requests to access patient information as required.
• Responds to patients’ or former patients’ requests for access to their own clinical record.
• Notifies attending physician and treatment team to advise of access requests.
• Follows up with patient regarding decision about access, establishes appointment for file review, advises of cost of photocopies, makes copies, and logs details in Meditech.

Accountability #6: Other Professional Responsibilities

• Prepares and scans documents in to the EHR
• Verifies scanned documents and electronically files in the HER
• Audit scanned documents as per Destruction of Scanned Documents Policy
• Trains H.I.M students from Community College.
• Assists, participates, and make recommendations/solutions in the formulation and implementation of the policies and procedures.
• Opening and closing of all inpatient and outpatient accounts
• Collects and provides statistical data for administrative or clinical use on an ad hoc basis.
• Tests the functionality of MPI/ADT patient information systems when up-grades are installed or new application system is purchased.

Accountability #7: Other Duties

• Works in a manner that complies with staff and patient/client safety practices, policies and procedures of the ROHCG.
• Ensures a work environment that is conducive to The Royal’s Anti-Racism, Discrimination & Harassment Free policy.
• Retrieves charts/file charts
• Participates in committees
• Other duties as required/assigned by the Director.

Qualifications:

• Community College Diploma (HIM) Health Information Management
• Certification with and member in ‘good standing’ with Canadian Health Information Management Association (CHIMA)
• Demonstrated experience with ICD 10 coding
• Knowledge and experience with Meditech an asset.
• Intermediate computer skills – Microsoft Office (Word/Excel)
• Keyboarding skills, speed of 20 words per minute with high accuracy
• Good organizational skills and interpersonal skills
• Strong attention to detail and ability to work under pressure
• Excellent communication skills both verbal and written
• Excellent attendance
• Ability to manage heavy workload and meet deadlines
• English level A- is mandatory in oral expression, oral comprehension, reading comprehension and written expression. Bilingualism an asset.