Health Information Services at Spring Grove Hospital Center shall
continually strive to achieve excellence in health care information
processing for the documentation of high quality patient care.
As a condition of employment in the Health Information Services
Department of Spring Grove Hospital Center, a potential employee must be
willing to sign the following agreement:
"As a condition of employment in the Health Information Services
Department of Spring Grove Hospital Center, I agree to abide by the
rules of confidentiality as dictated by Federal and State authorities
when handling the medical record of patients presently in the hospital
and those who have been discharged. Further, I will not discuss either
by name or inference any information concerning treatment, diagnoses,
and demographic or social data pertaining to patients in the hospital or
those who have discharged. I also understand that it is a federal
offense, punishable by fine or imprisonment to divulge information from
the medical record of a patient presently under treatment at Spring
Grove Hospital Center or a former patient without the written consent of
the person to whom it pertains or the consent of a legally appointed
guardian or representative acting on the behalf of a patient or former
patient. Also, I will not deny or confirm the whereabouts of any patient
admitted to this hospital unless a MISSING PERSON report has been filed
by the interested party or parties."
Hours or operation for Health Information Services are from
8:00-5:00, Monday thru Friday, excluding holidays. The office in the
Dayhoff is open six (6) days a week.
Central Health Information Services is located in the Smith Building where all records of discharged patients are kept.
Health Information Service offices are located in each patient
care building on the grounds of Spring Grove Hospital Center. All master
charts of patients who have more than one admission to the hospital are
maintained in the HIS office for patients in that building. The
responsibility of the HIS staff person is to handle all transcription
for psychiatrists, social workers, and psychologists. All requests for
information on inpatients are handled by the person assigned to the
area. Monthly and quarterly statistics for aftercare, admissions and
discharges are gathered and distributed by HIS staff for the purpose of
assisting in patient care. The department is very much involved in the
computerization of the medical record as plans move forward for a
completely automated patient record. HIS plays an integral part in the
ORYX program as mandated by JCAHO, assisting in data entry on a daily
To gain access to medical records in the Health Information
Service offices, proper identification is required in the form of a
state ID if an employee, driver license or other form of picture
By federal and state law, the medical record of any person
admitted to a mental institution is confidential and does not fall under
the general disclosure laws for general hospital admissions.
The staff of the Health Information Services department at Spring
Grove take every precaution to insure that the medical record is kept
confidential. No one is allowed access to information in the medical
record unless they are part of the treatment team..
A patient or the legally appointed representative of a patient
may have access to the information in the medical record by following
the proper procedure. In the event access is not granted, by law, a
summary of the record must be made available if the interested person
requests it in writing.
Before signing an Authorization for Release of Information, a
patient or former patient should read it very carefully, to insure that
no more information is disclosed than is authorized. For some
information released, a processing fee will be charged.
Medical records in psychiatric facilities in the State of
Maryland are maintained for a period of 25 years after the last
discharge. They are housed at the facility for 15 years and sent to the
State Archives for 10 years and then destroyed.
The only exceptions are records of patient who have died and are
only at the hospital on an (O)bservation (S)tatus. Death records are
kept for 10 years and then destroyed; OS records are kept for 6 years
and then destroyed
Health Information Services is directed by an individual who
meets the State of Maryland's established qualifications for the
classification of Health Records Program Manager.
All staff permanently assigned to Health Information Services
must complete an orientation period. This consists of but is not limited
to confidentiality of patient information, policies and procedures,
performance improvement activities and medical record documentation
requirements. At the end of orientation, the person is required to sign a
statement of completion and understanding. Supervisors are to discuss
at least one policy or procedure at each of their staff meetings. At the
quarterly meetings, educational quizzes or in-services are conducted.
Since Health Information Services at Spring Grove Hospital Center
is a very diversified department, staff assigned to work in the Health
Information Services offices must have a working knowledge of medical
terminology or be willing to take a course. They must be able to
transcribe at least 50 words a minute. Staff are trained to use the
coding manuals (ICD-9-CM and DSM-IV). Education in psychiatric record
keeping is ongoing.
Health Information Services is part of an ongoing student
training program here at the hospital. Students are referred mostly from
the Baltimore City Community College although some have been referred
from Essex Community College in the past when they had the Health
Information Technology Program.
Health Information Services will move forward with plans to take
further advantages of advancements in health information technologies.
This will be done in an effort to better serve our internal customers,
the patients, staff and outside agencies.
201 W. Preston Street, Baltimore, MD 21201-2399
(410) 767-6500 or 1-877-463-3464