Project Presentation
CHAPTER 3
HEALTH INFORMATION FUNCTIONS, PURPOSE, AND USERS
Purpose of the Health Record
Primary purpose:
Patient care
Management of patient care
Administrative purposes
Secondary Purpose
Education of healthcare professionals
Legal, accreditation, and policy development
Public health and research
Format of the Health Record
Paper health record – completely available in paper media
Electronic health record - a digital record of an individual’s health-related information that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.
Hybrid health record - is a combination of the paper health record and the EHR.
Users of the Health Record
Individual users - Individual users are those who depend on the health record to complete their jobs.
Patient care providers
Patient care managers and support staff
Coding and billing staff
Patients
Employers
Lawyers
Law enforcement officials
Healthcare researchers and clinical investigators
Government policy makers
Users of the Health Record Cont.
Institutional users - organizations that need access to health records to accomplish their mission.
Healthcare delivery organizations
Third-party payers
Medical review organizations
Research organizations
Educational organizations
Accreditation organizations
Government licensing agencies
Policy-making bodies
Overview of HIM Functions
Typical HIM functions include the following:
Medical transcription and voice recognition - Medical transcription, the process of deciphering and typing medical dictation, may be a part of the HIM department or it may be a separate centralized department where all transcription services are performed.
Disclosure of health information - the process of disclosing patient-identifiable information from the health record to another party.
Clinical coding and reimbursement – The amount of data abstracted for coding purposes varies by healthcare organization but includes data such as date of surgery, surgeon, and disposition of patient upon discharge (went home, transferred to another hospital, and so forth).
Overview of HIM Functions Cont.
Record storage and retrieval (paper and electronic) – Facilitates the transition from paper to electronic.
Master patient index – permanent record of all patients treated at a healthcare organization. It is used by the HIM department to look up patient demographics, dates of care, the patient’s health record number, and other data.
Record processing
Registries (cancer, trauma, birth defects, and more)
Birth and death certificate completion
Identification Systems
They link the patient to the health record. The health record number is a key data element in the MPI as it is a unique identifier for the patient. It is used to look up the patient’s health record number.
Paper Health Record – Serial Numbering System: In the serial numbering system, a patient is issued a unique numeric identifier for every encounter at the healthcare organization
Paper Health Record – Unit Numbering System: used in large healthcare organizations because it does not have many of the inefficiencies of the serial numbering system. The patient is issued a health record number at the first encounter and that number is used for all subsequent encounters.
Identification Systems Cont.
Paper Health Record – Serial-Unit Numbering System: combination of the serial and unit numbering systems
Paper Health Record – Alphabetic Filling System: used by small clinics and physician offices. The folders are filed alphabetically by the patient’s last name.
Electronic Health Record: The advantage of the EHR is that identifiers other than the health record number—such as the patient name and patient account number—can be used to retrieve the information.
HIM Interdepartmental Relationships
The HIM department must work with many departments to ensure they have the information that they need to perform their job. Departments include:
Patient registration
Billing department
Patient care department
Information systems
Quality management
HIM Information Systems
Disclosure of Health Information - The systems that track the disclosure of health information track requests for information from patients, insurance companies, and other requesters.
Chart Tracking - tracks the location of the health record but will eventually become obsolete when paper health records are eliminated. The chart tracking information system records who checked it out, where it went and how long it has been checked out.
Coding - An encoder assigns the diagnosis and procedure codes; the grouper uses the codes assigned to determine the diagnostic-related group or another grouping.
HIM Information Systems Cont.
Registries - registry is a database on specific diseases and procedures
Billing - HIM department may or may not directly use the billing system. The encoder and grouper may submit the codes and other data directly to the billing system or it may be entered manually by the coder.
Quality Improvement - they are repositories of data that are used to monitor trends, generate statistics, monitor outcomes, and improve the quality of the documentation in the EHR
Personal Health Records - A personal health record (PHR) is an electronic or paper health record maintained and updated by an individual for himself or herself; a tool that individuals can use to collect, track, and share past and current information about their health or the health of someone in their care.