HEALTH RECORDS

The health record of a patient documents the course of the individual’s treatment.  This applies to both in-patients and outpatients.  The record provides a means of communication between health providers for the assessment and delivery of current and future care of the individual.  It can also be used for fiscal planning and utilization management within the health facility.  Data is used to predict future health needs and evaluate and allocate funding to health facilities and services.

 The Health Records Department is responsible for the maintenance of these records.  In the department we process, analyze, code and abstract the charts before they are filed.  The attending physician dictates information, which is transcribed into the charts.  If the patient has an x-ray or ultrasound during their treatment this is also typed by health records staff and placed in the chart.  Once the chart is complete it is filed in a safe, secure place and kept readily available for the physicians to aid in the future care of the patient.  With the patient’s consent health records of patients can now be shared within the NEON Group.