Health Information Management Professional

**Position Information**

**Posting Number**:

- BMHC25-077E

**Title**:

- Health Information Management Professional (RFT 1.0 FTE)

**Position Status**:

- Regular Full-time

**FTE**:

- 1.0

**Job Schedule**:

- Days

**Department**:

- Clinical Information Services

**Union**:

- OPSEU Local 439

**Site**:

- Brockville Mental Health Centre

**About The Royal**
- As one of Canada’s foremost mental health care and academic health science centres, The Royal has a clear purpose: to get more people living with mental illness into recovery faster. This is at the core of everything we do and it is driven by the passion, focus and dedication of our employees. Every day, the work that we do transforms the lives of people with mental illness through specialized mental healthcare, advocacy, research and education._

The HIM Professional is responsible for ensuring the delivery of complete and accurate clinical records in full compliance with all applicable provincial legislation; for monitoring the Mental Health Act forms; for health record information management process which includes liaising directly with the clinical staff to facilitate this mandate. Ensures the confidentiality of patient information is respected and maintained in accordance with all ethical and legal requirements.

**Duties**:
**Accountability #1**:Quantitative Analysis of Clinical Records for Completeness**
- Performs a quantitative analysis of the clinical record for the completeness, accuracy, quality, validity and reliability and ensures the information meets hospital accreditation standards, statutory and legal requirements.
- Confirms accuracy of outpatient chart openings and re-openings as completed by the secretarial staff. Flags errors for correction and ensures final resolution.
- Inputs/edits chart deficiencies in the Meditech chart deficiency tracking system.
- Maintains Meditech Borrower files according to Program staffing.
- Monitors physician and discipline compliance with chart deficiency policy.
- Reports physician non-compliance to Director of Clinical Records and to the Clinical Directors.
- Reports discipline non-compliance to Director of Clinical Records, and Professional Practice Directors
- Maintains and dispatches deficiency letters of warning/suspension.
- Assists clinical staff with any inquiries / concerns regarding the chart deficiency process
- Assists Physicians and Allied Health Staff in the completion of their deficiencies.

**Accountability #2**:**Completion of RAI tool**
- Resolves/clarifies diagnoses with conflicting, missing or unclear information by consulting with the physician.
- Assists Allied Health Professionals and Physicians with completion of data in RAI tool.
- Retrieves selected data elements to complete the medical information on the RAI tool.

**Accountability #3**:Monitoring of Mental Health Act Forms**
- Reviews Mental Health Act forms pertaining to changes of patients’ legal status, for validity and correct calculation of time, identifying discrepancies and following up with clinical staff, including providing copies to Rights Advisor, and preparing forms for scanning to EHR
- Prepares and distribute monthly a report of upcoming expired forms to psychiatrists
- Enters data in Registration Legal Status screen and generates related reports for distribution to psychiatrists
- Communicates with the office of the Public Guardian and Trustee to ensure that declarations regarding financial capacity are processed efficiently and correctly
- Monitors requests for clozapine funding by keeping a log of all requests, prepares letters for the interim clozapine coordinator to approve or deny funding; faxes all approved or denied funding letters to the requesting physician and to the finance department and files each request

**Accountability #4**:**Registration**
- Entering and updating inpatient and outpatient data onto Admissions/Discharges/Transfers (ADT) System.
- Prints inactive case lists, on a quarterly basis to discharge outpatient admissions.
- Completes final analysis of the clinical record.
- Assigns deficiencies to appropriate physician and other clinicians to complete closure procedure.
- Notifies staff physicians’ secretaries to book time and close their charts.
- Ensures physician has completed outpatient discharge order before discharging outpatient account.
- Discharges account in registration module, once charts are closed and complete with final diagnosis, by entering date of discharge and disposition.

**Accountability #5**:Release of patient information**
- Accepts processes and responds to requests to access patient information as required.
- Responds to patients’ or former patients’ requests for access to their own clinical record.
- Notifies attending physician and treatment team to advise of access requests.
- Follows up with patient regarding decision about access, establishes appointment for file review, advises of cost of photocopies, makes copies, and logs details in Meditech