Health Information Management

Health Information Management (HIM) is under Revenue Cycle Management Department within the Finance Division. HIM is entrusted with safeguarding patient medical records (paper chart and electronic format) for medical services provided within Fort Defiance Indian Hospital Board, Inc. (FDIHB) facilities.

HIM handles, analyzes, and protects digital and paper medical information vital to providing quality to our patients. We are currently in the turning paper records into an electronic format. We are also working on providing access to patients for Personal Health Record (PHR), which also provide a secure email using Direct Messaging with FDIHB Providers. We work with other facilities using Health Information Exchange, which is using electronic secure communication, so our patients can get the care they need at other facilities. We still have the traditional Release of Information (ROI), where patient comes in to sign consent to release patient information elsewhere. We also have coders, who obtain codes from provider notes, so we can get reimbursement and improve our data quality.

Services

Release of Information (ROI)

On July 15, 2015, HIM has gone paperless charts, no more creating new paper charts cutting down new chart turnaround to five minutes. On October 18, 2017, ROI began using an electronic eFax process. Paper records which took two weeks to complete the ROI and the turnaround time for eFax is now one to three days for send out. The only time it takes longer is when the medical records was sent to archiving, so it takes about two weeks to get the medical records back; however, HIM will inform patient when this occurs.
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Authorization For Use or Disclosure of Protected Health Information
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‍ROI is the patients consent, the authorization for use or disclosure of protected health information. It gives the HIM department the right to release only specific, needed (not entire) medical information to outside health care facility. Mental health notes are released with Mental Health Provider’s approval and a valid identification is required to comply with federal regulations.

PHR/Direct Messaging

Personal Health Records (PHR) is an electronic application designed specifically for patients to view and access their personal medical records through a website portal provided by The Indian Health Service. With PHR, patients have a more convenient, secured, private management of their IHS visits throughout the country. PHR links your IHS visits to one portal site for reviewing, downloading, printing and contacting a health care provider all from your personal computer, mobile device, and tablet.

Information available in PHR:

• Medication List
• Test Results
• Appointments List
• Health Issues
• Immunizations
• Vital Signs

Personal Secure Direct Messaging Email

You can register at Personal Health Record Login. After completing your registration visit the HIM Department with a valid identification card and we will link you medical record to your PHR account.

Personal Health Record

Direct Messaging

After you have registered with PHR, you can send an email message (direct messaging) to your health care team. Your email message will be delivered to fdihb@fdihb.directihs.net. Your message will be directed to your health care team. This e-mail should only be used for health information. Messages may be added to your medical record.

Do not use e-mail for emergencies. If you are having an emergency, call 911.

Notary

The HIM Department also provides notary services. A notary is an impartial witness appointed by the state to witness your signature in person. Please bring valid identification and please, do not sign documents until you speak with one of our Notaries. Thank you.

Scanning

All documents pertaining to patient treatment and consents are scanned, reviewed and finalized, so providers are able to have patient medical information to provide medical diagnosis and treatment. HIM is able to scan all documents into Vista Imaging and providers are able to see these scanned documents in the Electronic Health Record.

Birth Certificates

FDIHB submits all live births that occurred in the hospital to the state of Arizona to process birth certificates; Electronic Birth Registration System (EBRS) requires a “Certificate of Live Birth Worksheet” to be completed.

If parents are not married an Acknowledgement of Paternity (AOP) will be required. Once all required information and signatures are received, FDIHB submits online within seven days of birth.

If a correction is required, FDIHB will refer to the “Certificate of Live Birth Worksheet” on file. If FDIHB created the error, we will work with AZ Vitals for corrections. If the error was created by the parents or the informant on record, they will have to work with AZ Vitals and FDIHB will not be able to make any corrections.

Deaths

FDIHB submits patient information on deaths occurring with the hospital to the state of Arizona to process death certificates; Database Application for Vital Events (D.A.V.E.) requires providers to enter vital information online. Mortuaries will then continue the process for a death certificate. We work closely with Medical Examiners, Criminal Investigators and Mortuaries to assist in the Death Certificate process.