Health Records and Health Information Management

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Health Records and Health Information Management
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Health Records

• Permanent or long-lasting document of all patient
  care information that applies to an individual.

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Health Information Management Department

• An organized, staffed, department which provides
  adequate record management through systems and
  practices.
• This group facilitates the use of the health
  record and protects the content of the record
  against unauthorized disclosure.

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Health Information Management Department

• Functions also include support of current and
  continuing care of patients the institutions
  administrative processes patient billing and
  accounting processes medical education programs
  health services research utilization management
  risk management, and quality assurance programs
  legal requirements and extraneous patient
  services.

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Health Information Management Practitioners

• Registered Health Information Technician (RHIT)
  formally known as Accredited Record Technician
  (ART) professional skilled in collection,
  analysis and reporting of health care data and
  provision of support to health care.

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Health Information Management Practitioners

• Registered Health Information Administrator
  (RHIA) formally known as Registered Record
  Administrator (RRA) professional skilled in the
  interpretation and analysis of health care data,
  design on information systems, and management of
  health care information systems operations.

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Changes in HIM

• Prospective Payment System (PPS) system for
  Medicare hospital inpatients whereby payment
  groups are established in advance.
• Diagnosis-related Groups (DRGs) system that
  categorized into payment groups patients who are
  medically related with respect to diagnosis and
  treatment and statistically similar with regard
  to length of stay.

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Health Record Content

• Patient identification data
• Medical Hx of the patient, including chief
  complaintpresent illness or injury relevant
  past, family and social HX and inventory by body
  system.

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Health Record Content

• Report of relevant physical examination
• Diagnostic and therapeutic orders
• Clinical observations, including results of
  therapy

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Health Record Content

• Reports of diagnostic and therapeutic procedures
  and test as well as their results
• Evidence of appropriate informed consent

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Health Record Content

• Conclusions at termination of hospitalization to
  evaluation of treatment, including any pertinent
  instructions for follow-up care.

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The Health Record in Radiology

• Order for exam
• Documentation of the exam
• Results of exam

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Health Records in Reimbursement

• International Classification of Diseases, 9th
  edition, Clinical Modification (ICD-9-CM)
  universal statistical classification system used
  throughout the US and the world for coding and
  reporting diagnoses and procedures.
• Current Procedural Terminology(CPT) -
  comprehensive listing of medical terms and codes
  for the uniform designation of diagnostic and
  therapeutic procedures.

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Quality Management

• Monitors and evaluates the quality of the care
  and services provided to patients within a health
  care facility.
• Also called Quality Assurance and Quality
  Assessment.

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Quality Management Plan Components

• Objectives what the program is intended to
  achieve, at what level, and under what
  circumstances.
• Organization the chain of command and the
  responsibilities of various persons and groups
  within the organization

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Quality Management Plan Components

• Scope the programs emphasis on hospital wide
  participation
• Monitoring the programs mechanism for the
  repeated measurement of various aspects of
  clinical decision making and patient management.

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Quality Management Plan Components

• Evaluation the programs procedure for
  assessment and documentation of its effectiveness
  in meeting established objectives

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Quality Management Plan Components

• Efficacy the degree to which the care of the
  patient has been shown to accomplish the desired
  or projected outcome.

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JCAHO Dimensions of Performance

• Efficacy
• Availability
• Effectiveness
• Continuity
• Safety
• Efficiency
• Respect and caring

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Legal Aspects of Health Records

• The record is an important legal document that is
  used by the health care institution to define
  what was or was not done to the patient.

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Correcting the Health Record

• Must be done in an appropriate manner to be
  considered a change in the record.

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Confidentiality of Health Records

• RT bears responsibility to maintain the
  confidentiality of health records.
• The patient-physician privilege states that a
  physician cannot testify in court without the
  consent of the patient.
• Released information should be in writing from
  the patient or legal representative.

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Fax Transmission

• Example on pg 323 of Fax procedure

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Patient Access to the Health Record

• The health Insurance Portability and
  Accountability Act (HIPA) of 1996 mandates that
  federal laws regulate the confidentiality of
  medical records.

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