Patient Information & Records

Centrally managed tools to aid in the dictation, transcription and storage of medical documentation

Clinical Forms & Document Management
Front end voice to text recognition software via Fluency Direct (M*Modal)

Oversight & Systems
We are a multi-disciplinary team that reviews clinical form requests, coordinates the building of such forms with UVA Printing & Copying Services, and offers demand print options via HS/TS imaged devices.
Reviews and validates appropriateness of access requests to PHI systems by Non-UVA or UPG personnel.
Responsible for providing customer support, software installation, application utilization, and access to the 3M, PDAPro, and M*Modal systems. Serves as the liaison between HIS and other technology teams and is responsible for technology inventory and purchasing.

Patient Services & Release of Information
Provides an Accounting of Disclosure report to patient's or attorneys upon their request, per HIPAA rules and regulations.
Audits master patient index data to ensure that patient's have a single medical record, modifies demographic information with proper authenticating documentation, schedules appointments, merges electronic and paper health information, assigns alias identities, and investigates suspected identity theft.
Coordinates the request, review, and decision regarding patient requests to amend their health information.
Coordinates the request, review, and decision regarding patient requests to restrict their health information.
Serves as the Custodian of Record (HIS Administrator and Leadership). Controls and oversees the release of information, including audit data, from the health record of any patient treated at the UVA Medical Center or clinic affiliated with UVA. Release media types include paper, CD, and MyChart. Responds to all requests for access upon receipt of proper authorization. Assures the confidentiality and security of health records while releasing medical information in accordance with state and federal statues and regulations and hospital policies. Validates proxy access for MyChart users and coordinates the viewing of records.
Coordinates and authorizes access to health records available for viewing via the Epic-Release to Inspector application (e.g. Medical Examiners, Case Managers, Child & Adult Protective Services, Study Monitors, Auditors, etc.).

Provider Services- Dictation, transcription, & Provider Database Management
HIS Administrator or Manager (as designated) is responsible for certifying and notarizing procedure reports for Board Certifications and Recertifications.
We maintain the UVa and Referring Provider databases, including the validation of said clinician demographic and contact information.
Medical dictation via M*Modal
Coordinates the request, review, and implementation regarding provider requests to restrict patient's health information

Records Management & Scanning
Retrieval of health information for scanning into On-Base/Epic.
Manages the retention and destruction of all medical records including those in the EMR, hard copy and filmed media format.
Importing or scanning images into On-Base, which are then bridged and available for viewing in Epic under the Media Tab. Scanned images are indexed to the correct patient, account and document type for retrieval of health information data. Images are audited for accuracy and quality of prepping, scanning, and indexing.