As the “gatherer and safe keeper” of all information generated or created on each patient throughout the hospital, the HIM/Medical Records Department has a variety of responsibilities, each of which directly addresses patient safety in one form or another.

This department is tasked with ensuring that each assembled page of a patient’s medical record does in fact belong to that patient. By certifying that every encounter is complete and accurate, the HIM/Medical Records Department provides added support for patient care, treatment and services, while enforcing optimal coding and billing compliance standards. When any discrepancies are noted or questioned (i.e. patient name, DOB, SSN, etc.), the HIM staff will contact the specific ancillary department for assistance in clarification.

Furthermore, the privacy and security of the patient record retained in accordance with mandated laws and regulations is another critical aspect within the jurisdiction of the HIM/Medical Records Department. Staff must ensure that all medical records and health information is protected against unauthorized access, use and disclosure. They are responsible for seeing that all policies and procedures are followed defining when and by whom the access or removal of any record is permitted. In essence, they are HIPAA’s “ambassadors” at Coast Plaza. The HIM/Medical Records department works in close conjunction with the medical staff, adding its oversight for clarification of diagnoses or procedures as they relate to a patient’s medical record. By protecting each patient’s privacy and monitoring all medical records, they are an integral part of the Coast Plaza team.

The California Department of Public Health (CDPH) has recently released a selection of frequently Asked Questions relating to infectious disease health care issues within the medical community. The list is as follows:

1-Q) “Is there a requirement to perform a screening culture on a patient known to be positive for MRSA to maintain compliance? Understanding that the majority of this population is colonized and have not been treated to attempt to decolonize MRSA, we have always placed them in Contact Isolation. Example: Patient is admitted to ICU with a known documented history of MRSA. Per SB 1058, the patient is required to have a screening culture for MRSA.”

1-A) SB 1058 requires that all patients admitted to the ICU be screened and also makes additional requirements for patients who test positive (informing and aftercare instructions). However, it is also preferable not to use valuable resources to screen patients unnecessarily. To avoid unnecessary screening, it is important that hospitals be able to demonstrate that SB 1058 has been effectively complied with in the absence of additional screening. In order to do so the hospital must demonstrate that patients known to be already colonized are treated exactly the same as they would be if they were screened and tested positive on the current admission, according to hospital policies and procedures for positive patients. This includes all of the requirements for the follow-up of patients who test positive. If they have previously been informed and instructed, this process can be modified on the current admission to take that into account, along with the consideration that patients may not accurately recall instructions they received on a previous admission.

2-Q) How is “admitted to the ICU” in the above phrase to be interpreted?

2-A) This question was sent to the legal department with the following response: the phrase may be interpreted as “there is no requirement to test patients who are admitted elsewhere, then later transferred to ICU. The focus is on the plan at admission.”

3-Q) Multiple emails have been received from hospitals where the IC Chair needs his/her CME in infection control. Does CDPH know of any upcoming courses that will meet this requirement? Do courses at infectious diseases conferences meet this requirement?

3-A) The key requirement is “The CME program shall be specific to infection surveillance, prevention, and control.” The law is clear in this regard. Infectious Diseases is a different specialty than Infection Prevention and Control. While waiting for a course that meets the above qualification the Chair could take a course to demonstrate a good faith effort to partially fulfill the requirement but that would not exempt them from taking a qualifying course once one became available.

This is to remind all employees and their families that Coast Plaza Hospital will be offering a free seminar addressing topics, issues and treatments dealing with GERD and other heartburn related symptoms. This seminar will take place on Tuesday, February 16th, between 6:30 and 8:30 pm in the Norwalk Arts and Sports Complex, Sproul Room, 13000 Clarkdale Avenue, Norwalk, CA, 90650. If you or someone you love cannot eat, drink or sleep as you wish due to the effects of GERD, I urge you to attend the seminar or contact the Coast Plaza Digestive Health Center at 1-877-900-6399 to schedule an appointment.

RSVP: 1-877-900-NEW-YOU or 1-877-900-6399

Coast Plaza is proud to have as part of its Medical Staff Dr. Nancy Sand, a board certified ophthalmologist who completed her ophthalmology training at the prestigious USC Doheny-Eye Institute. Dr. Sand finished her internship at St.Vincent Medical Center in New York, and then earned her medical degree from Geottingen University in Germany. Dr. Sand’s scope of services includes complete comprehensive ophthalmology eye care for diseases and conditions such as blepharitis, dry eyes, glaucoma, cataracts, eye lid diseases, floaters, and macular degeneration. Her experience in diagnosing and treating diabetic retinopathy, a disease of the eye causing damage to the retina due to complications of diabetes mellitus, makes her a welcome complement to the Hospital’s diabetic program, with whom she will be working closely. Dr. Sand has further expertise in microsurgery procedures including premium cataract surgery, laser vision correction (Lasik, PRK) and plastic surgery of the eye.

Although February is the shortest month of the year, the month has already proven to be one of the busiest. It goes without saying, of course, that Coast Plaza is here for the challenge, and its community, 24 hours a day, every day.