Health Information Management (HIM) is the process of protecting, analyzing, inspecting and acquiring medical information such as health records, each time a patient is seen by a healthcare provider. The HIM professional is an important connection between doctors, nurses, patients, insurance companies and everyone in the medical field. Every time a healthcare professional sees and treats a patient, they record what they observed, how the patient was treated medically, and future steps in the treatment plan discussed between the patient and the healthcare worker. The medical record includes the patient’s symptoms, medical history that includes past, present, and family history, results of studies, such as x-ray reports, or lab results, diagnosis,
List and define five medical office specialist’s job titles and responsibilities Medical Office Assistant Define: Usually a certified person who work alongside the physician in an outpatient or ambulatory care setting. Discuss: This position entails administrative duties such as scheduling patient’s appointments, compile and record medical records, answer the telephone and direct staff. This person may also be cross trained in clinical duties such as drawing blood, assisting during the exam, and acting as a liaison between the patient and the physician.
I would like to become a Health Information Technician, properly known as Registered Health Information Technician or RHIT. This position appeals to me for a couple reasons. One is because I like the medical field but do not have the heart to be a doctor (it seems too sad to me). I also like technology and this combines two of my interests into one job so therefore I believe it is a good career option for me.
#1- Compare and contrast the clinical uses of a health record with the secondary purposes of a health record.
Biomedical equipment technicians have a very critical role in the medical community. They are the ones that make sure the medical equipment used on a daily basis functions properly for an accurate diagnosis. Biomedical equipment technicians inspect, test, repair, and perform routine maintenance to a myriad of medical machinery in order to ensure the users ' and patients ' safety. Biomedical equipment technicians use their technological expertise to prevent mechanical and computer errors that could lead providers to the wrong diagnosis. They also set up preventative maintenance programs to keep equipment running and prevent life-threatening
Health information exchange or HIE allows doctors, nurses, pharmacists, and other health care providers and patients to access vital medical information. It also allows them to share medical information securely and electronically. HIE improves the speed, quality, safety, and the cost of patient care. For many years patient's files were stored using paper methods, transferring them by mail, fax or transferred it by hand to every appointment. Changing to electronic file improves the completeness of patient's medical records.
The policies and procedures should address the following areas that include, effective communication among various entities in the organization, education and training program for the every department, and most especially the HIM department, implementation of communication channel within the HIM department and other department in the organization, procedures for appropriate disciplinary action/corrective measures, and auditing/monitoring system. Furthermore, the policies and procedures should outline specific action plans that should be followed in the HIM department; the policies and procedures will be fashioned to adhere the guidelines and recommendations of major accrediting and professional organizations such as the American Health Information Management Association (AHIMA), the American Hospital Association (AHA), and National Center for Health Statistics. The issue of medical record availability should be addressed to specify the document requirements necessary for effective coding practice, and also the establishment of the role of physician advisor should be considered in order provide guidance on coding issue and to act as liaison between medical staff and the HIM department. Additionally, as part of the effort to address the coding issues, the HIM coordinator should set goals that will guarantee 100% coding accuracy report and less
Role of Graduate Nurse in Informatics are: 1) computer generated nursing care plan for each patient. 2) reminder and prompts that appear during documentation to ensure comprehensive charting. 3) help as a communication aid to other health care professionals taking care of the same patient. For example, Electronic Health Record. The role of Advanced Practice Nurses and Registered Nurses are same in Informatics regarding accessing, protecting and documenting patients Electronic Health Record(EHR).
Health Information Exchange Providers across the U.S. are turning to the Health Information Exchange also known as HIE. HIE provides secure online access to patients charts among a network of providers, hospitals, clinics, doctor’s offices, and pharmacies who join in the exchange, so they can have timely electronic access to records their patients will allow them to share. For patients this means having their medical records available no matter where they go and for providers it means having instant access to life saving information when seconds count
“Electronic health information exchange (HIE) allows doctors, nurses, pharmacists, other health care providers and patients to appropriately access and securely share a patient’s vital medical information electronically—improving the speed, quality, safety and cost of patient care” (HealthIT, 2014). Health Information exchange is becoming important in the communication between providers to provide the best care possible to patients. Every state along with their hospitals has their own way of exchanging information between each other.
Technology is used in the health care system to chart patient health information, communicate with the interprofessional team, and monitor plan of care. The nurse, upon licensure, recognizes the importance of computer literacy and the effect technology has on patient outcomes. The use of technology can hinder or help the patient based on its use. For this reason,
Assignment – There are five common purposes for medical records. List each of these purposes and provide an example of each in healthcare. Having good medical records is very important, for the proper care of patients. “Medical records can be used to manage healthcare, track healthcare, provide clinical data, meet regulatory requirements, and document healthcare” (Allen, 2013, P. 57). Without the proper documentation there is no proof that it was ever done.
Description of the legislation/policy Health information technology can advance the health of individuals and aid with the performance of providers to produce and improve quality and cost savings in patients’ health. In 2009, Congress passed, and former President Obama signed into law the Health Information Technology for Economic and Clinical Health (HITECH) Act, as part of the American Recovery and Reinvestment Act (Buntin, Burke, Hoaglin and Blumenthal, 2011). Authorized by the HITECH Act, the Office of the National Coordinator for Health Information Technology’s (ONC) has worked on health IT. The Health IT created legislation and regulations to provide requirements and certification criteria that the EHRs must meet to ensure health care
I will summarize each outcome for the Nursing Informatics specialty. For the intent of this paper I will use outcome and competency interchangeably. The first outcome means the ability to gather healthcare information across the continuum of care; combine and utilize the information gathered to develop a process. Finally execution of that process to evaluate its ability to improve the quality of the healthcare environment. Healthcare managers are constantly assessing patients and collecting information.