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The functions of HIM
ensure quality, security, and availability of health information
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The HIM dept monitors
- quality of patient info
- ensures info is maintained and protected according to regulations
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HIM most important function
Storage and retrieval of patient information
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HIM typically manages the following services
- Record processing
- Monitioring of record copletion
- Transcription
- Release of patient information
- Clinical coding
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2 types of Transcription
- Textual--What is written
- Contextual-- What is interpreted
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HIM typically manages the following functions
- Research and statistics
- Cancer and/or trauma registries
- Birth Cert. completion
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This is implemented to determine what work and what doesn't. And what needs to be changed
Workflow Analysis
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These were established to mirror the any processes and uses of the electronic health record
Work Queues
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Examples of work queues
- Quality Review
- "Loose Sheets" queues
- Birth Certificate queues
- Medical Coding queues
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Name for lab and x-ray coding
Ancillary Coding
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EDMS
Electronic Document Management System
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These are considered the most fundamental responsibilities of most HIM depts
- Storage and Retrieval
- Record Processing
- Record Completion
- Treanscription
- Release of Information
- Clinical Coding
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Branches of HIM Services
Record Processing---Assembly, Storage/Retrieval,Record completion, Medical Transcription
Compliance/Research---Clinical Coding, Research
Release of Information---Requests for patient info, Birth Certificates
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Most important index used by HIM
Master Patient Index
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This functions as the primary guide to locating pertinent demographic data about the patient and his or her health record number
Master Patient Index
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Basic Information of the Master Patient Index
- Last, First and Middle Name
- Health Record Number
- Date of Birth
- Gender
- Dates of Encounter
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R-ADT
Registration, Admission,Discharge, Transfer System
AKA--Patient Registration System
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Benefits of the R-ADT
Ability to access data by ore than one individual at a time
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This permits the use of several search tecniques for locating an existing patient's information
Electronic MPI
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What is some major concerns of a Manual MPI
- Misfiled Cards
- Only one person at a time can access the index
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Name some errors that both manual and electronic MPI can contain
- Misspellings
- Incorrect demographic data
- Transposition of Nubers
- Typographical Errors
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If a incomplete or rushed search of an electronic MPI is conducted, what could happen
Can cause a creation of a duplicate record nuber for an individual or match an individual with the wrong health record number
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The most common MPI errors occur when
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At the point of registration when existing MPI info is not located
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This is the assignment of a new patient medical record nuber to an individual that has an existing medical record number.
Duplicate Medical Record Number
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This is where a patient is assigned another person's medical record number
What is the possible outcome
Overlay
The medical information of two or more individuals are combined, resulting in problems identifying what medical information belongs to which patient
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This is when one or more medical record numbers exists for the same patient.
Mostly occur where
Overlap
- Occurs in multiple facilities--Multi-hospital systems
- Health Info Exchanges
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EMPI
Enterprise Master Person/Patient Index
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This is when 2 different MPI's combine and make 1 huge system
EMPI (Enterprise Master Person/Patient Index
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Frequently used to describe both the sharing of health information electronicallly among two or more entites and also an organization that provides services to accomplish this inforation exchange
HIE----Health Information Exchange
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A key data element in the MPI, it is used as a unique personal identifier and also used in paper based nuerical filing systems to locate and link records
Health Record Number (aka. medical record number)
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This number identifies not only the patient, but also the patient's record
Health Record Number
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This type of idenification should not be used as patient identifiers
Social Security Numbers
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Name the identification systems used for Paper-based health records
- Serial Numbering
- Serial Unit Numbering System
- Alphabetic Identification and Numbering System
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In this system, a patient receives a unique numerical identifier for each encounter or admission to a healthcare facility. It is issued in a series
Serial Numbering System
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Disadvantage to the serial numbering system
The information about the patient's care and treatment is filed in separate health records at separate locations. Makes retrieval of info less efficient and storage more costly
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Most commonly used system in healthcare facilities.
A patient receives a unique health record number at the time of the first encounter. Each time the patient has another encounter, the same number is used.
Unit Numbering System
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What is the advantage of the Unit Numbering System
All the information, regardless of the number of encounters can be filed or linked together
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The Unit Numbering System works best in what environment
Computerized
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In this system, numbers are assigned in a serial manner, however during each encounter, the previous health records are brough forward and filed under the latest health record number. It creates a unit record
Serial Unit Numbering System
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This system helps alleivate the problem of access to previous patient demographic and health record number informationl.
Helps to address problems associated with retrieval and the cost of the serial system
Serial Unit Numbering system
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This system is usually used in small facilities
The patient's last name is used as the first source of identification and his or her first name provide further identification
Alphabetic Identification and Filing System
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Advantages and Disadvantages of Alphabetic Filing System
Simple to locate health record w.out finding a assigned number
In a given community, several people may have the same name
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All forms should
Contain a unique identifier
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