Health Records: Essential to Providing Excellent Patient Care

If you have ever visited the hospital, you likely encountered a nurse, physician, or other health professional, as well as employees from housekeeping, food and nutrition, and possibly administration.

But it is unlikely you met another critical member of your health care team. That is because the 55 employees in the Health Records department at Thunder Bay Regional Health Sciences Centre (TBRHSC) work behind the scenes to ensure your care is meticulously charted.

Some of the functions performed in Health Records include the transcription of medical and surgical reports, coding diagnoses and surgical procedures, releasing health information, retrieving, storing, filing, and scanning medical information and report writing of the coded information. The department is also responsible for ensuring privacy legislation is adhered to at TBRHSC.

“A lot of what we do is driven by legislation, particularly the Public Hospitals Act,” says Heidi Greenwell, Manager, Health Records. Accuracy is of the utmost importance. “Data quality is an important part of what we do. We run 150 data quality reports before they’re submitted to the Ministry of Health and Long-Term Care at the end of each month.”

Employees in Health Records play an essential role in terms of quality, efficiency, and trend analysis. Data provided to hospital administration can help leadership at TBRHSC see current trends and projections. “For example, we can compare our readmission rates to other hospitals in the province or even other provinces and look at how we’re different, why, and how can we improve,” says Greenwell. That data is also an essential element to any proposals for new funding, programs, or services.

Because Health Records provides patient chart reviews and reports for health care providers that help

clinical decisions, the department is essential to TBRHSC’s ability to provide excellent patient care. The implementation of scanning records streamlines clinical access.

Once a patient is discharged, their record comes to Health Records. The department processes a staggering volume, 17,500 inpatient discharges annually and transcribing 4 million lines annually.

“For clinicians, the Health Record is essential to providing good care to our patients,” says Dr. Bill McCready, Interim President and CEO, TBRHSC, and Interim CEO, Thunder Bay Regional Research Institute. “The Health Records staff make sure these records are organized, available, and relevant to the clinical staff, while protecting the privacy of the patient. We all owe the staff of Health Records a debt of gratitude for the work they do.”