Services provided by Health Records Services at PHC are an integral part of all patient care. Our department consists of the following areas:

Records Management
The Records Management department creates, assembles, stores and provides records to caregivers. We ensure quality and confidentiality of documentation in compliance with legislation, hospital bylaws, and Ministry of Health Guidelines.

Our department is a nationally recognized industry leader for its extensive adoption of records scanning systems. We scan approximately 20,000 records each day, and since April 2006 have supported patient care by providing caregivers secure online access to over 350,000 documents per month. This enables over 3000 physicians, nurses and allied health staff to get the information they need where and when they need it.

Health Records at PHC plays a key role with Quality Assurance and our Health Record Technicians review all inpatient and surgical cases to ensure minimum documentation requirements are met.

In addition to supporting PHC caregivers, we provide extensive support to others with legitimate needs to access our patients' records such as family physicians, other emergency departments, insurance agencies, and patients themselves. We assess all health record information requests in compliance with FOIPPA (Freedom of Information & Protection of Privacy Act) and corporate policies, and provide records where appropriate. In 2006, we processed approximately 15,000 requests for patient information.

The staff working in Records Management are highly regarded for their accuracy, valued for their close attention to detail and appreciated for their extensive knowledge of over 2000 clinical forms.

Transcription Services
Physicians and other health care providers employ state-of-the-art electronic technology to dictate and transmit highly technical and confidential information for their patients. These medical professionals rely on skilled medical transcriptionists to transform spoken words into comprehensive records that accurately communicate medical information.

The primary skills necessary for performance of quality medical transcription are extensive medical knowledge and understanding, sound judgement, deductive reasoning, and the ability to detect medical inconsistencies in dictation.

Medical understanding is critical for the professional medical transcriptionist. The complex forms used in medicine are unlike the language of any other profession. Medical transcription requires a practical knowledge of medical language, anatomy, physiology, disease processes, pharmacology, laboratory medicine, and the internal organization of medical reports.

The medical transcriptionist at Providence Health Care is part of a team of professionals who have led the way in utilizing speech recognition technology in the region. Speech recognition is being used for all medical specialties and report types. Utilizing a mix of traditional transcription as well as speech recognition allows for a wide variety of work and eliminates the potential for boredom, and lessens stress and strain, which can lead to repetitive stress type injuries.

We transcribe the dictated reports of over 400 care providers for inpatient and outpatient areas and provide transcribed copies to caregivers and records management. Physicians dictate 124,000 reports, for a total of 8,100 hours per year and approximately 850 faxed reports are sent out each day.

Coding and Data Support
Our Coding and Data Support department is comprised of 11 Health Record Coders who are experienced, skilled professionals certified by the Canadian College of Health Information Management (CCHIM). These Coders are governed by coding standards put in place by the Canadian Institute for Health Information (CIHI) as well as the Ministry of Health (MOH) and the World Health Organization (WHO).

Coders use their wide knowledge of anatomy, physiology, and disease processes to review all records and assign codes for various procedures and diagnoses. By taking the story of a patient, following coding standards and transforming the clinical story into standardized data, we provide invaluable information, which can then be used for planning, research, funding, quality assessment, and improvement. These statistics are used at the hospital level as well as for provincial and national purposes.