HI150 Unit 10 Department Procedure Manual Example

Could Someone Hired Last Month Follow It Without Asking Anyone: A Unit 10 Department Procedure Manual With Three Procedures for a Composite Health Information Department, From Index Search to Loose-Document Scanning

[Student Name]

Purdue University Global

HI150: Automation of Health Information 1

Unit 10 Department Procedure Manual

[Instructor Name]

[Date]

The department, its system and its contacts are composite; the requirements the procedures apply and the sources cited are real.

Introduction

This manual is for staff in health information management and patient access. It replaces the department's 2019 notes. Procedures are self-contained; follow the one for the task in front of you. Questions go to the person named at the end of each procedure.

Procedure 1: Patient Index Search Before Creating a Record

Header: performed by patient access and index staff; requires registration access; revised October 2026. Prerequisites: the patient or family is present or on the phone; photo identification if available.

1. Enter last name and date of birth only. Leave first name blank.

2. Review every result with a matching date of birth.

3. If no result appears, search again by last name and the first three letters of the first name, then by phone number.

4. For a newborn under three months, also search by the mother's name and the date of birth, since newborns are registered under a temporary name.

5. Decision point: if one candidate matches on at least two identifiers in addition to name, such as date of birth and address or phone, select it.

6. If more than one candidate appears, do not choose. Call the index coordinator before continuing.

7. If no candidate matches after all searches, create a new record and note in the comment field which searches were run.

Handoff: the registration continues. Quality check: the index coordinator reviews all new records created each day for possible duplicates. Discrepancies in identifying fields are the main reason patient searches fail, which is why the procedure searches on fewer fields first (Just et al., 2016). Contact: index coordinator, extension 4412. Step 1 leaves the first name blank on purpose, because nicknames, spelling and newborn names break more searches than any other field.

Procedure 2: Deficiency Notification

Header: performed by deficiency analysts; requires deficiency module access; revised October 2026.

1. Open the discharged encounter from the analysis queue.

2. Compare the record with the checklist for the encounter type.

3. For each missing or unsigned item, assign a deficiency to the responsible clinician under the medical staff rules.

4. Decision point: if the responsible clinician is unclear, assign to the attending of record and note it.

5. Send notifications from the system; do not email.

6. On day 15 after discharge, review open items; send a reminder.

7. On day 21, notify the medical staff office.

Handoff: completed records release automatically to coding. Quality check: weekly count of records over 30 days, the federal completion limit for hospital records (42 C.F.R. § 482.24, 2024). Contact: deficiency lead, extension 4420.

Procedure 3: Loose-Document Scanning

Header: performed by scanning technicians; requires scanning and index access; revised October 2026.

1. Sort received documents by patient, then by date of service.

2. Set the scanner to two-sided.

3. Scan one patient's documents at a time.

4. Confirm two identifiers on each document, name and date of birth, before indexing.

5. Select the encounter by the date on the document; never accept the default.

6. Select the document type from the list; outside records go under outside records, not correspondence.

7. Decision point: if a document has only one identifier or none, place it in the hold tray and notify the scanning lead.

8. Keep paper originals in the dated bin for 30 days.

Handoff: indexed documents appear in the record immediately. Quality check: the scanning lead reviews a 60-document sample monthly. Contact: scanning lead, extension 4431.

Why These Three Procedures Come First

The department chose these three because each sits at a point where one person's quick decision shapes every record that follows. A missed index search creates a duplicate that splits a patient's history, and the error spreads with every document filed afterward. A deficiency sent to the wrong clinician sits unanswered until the record is overdue and the claim is held. An image filed under the wrong person or visit can stay hidden for months. The department's own reviews over the past year found errors at all three points, and new staff learned each task from whoever happened to be on shift, which is how slightly different versions of each task spread. Writing them down once, in the same format, lets the supervisor train against one standard and lets the quality checks at the end of each procedure measure whether the standard is being followed. Further procedures, for release of information and coding queries, will follow the same template next quarter.

Review

The supervisor reviews this manual each January and whenever the system changes. Any staff member may propose a correction by sending it to the supervisor. Superseded versions are kept for six years, the period the privacy rule sets for retaining required policies and procedures (45 C.F.R. § 164.530, 2024).

References

42 C.F.R. § 482.24 (2024). https://www.ecfr.gov/current/title-42/section-482.24

45 C.F.R. § 164.530 (2024). https://www.ecfr.gov/current/title-45/section-164.530

Just, B. H., Marc, D., Munns, M., & Sandefer, R. (2016). Why patient matching is a challenge: Research on master patient index (MPI) data discrepancies in key identifying fields. Perspectives in Health Information Management, 13(Spring), 1e.