1. The functions of HIM
    ensure quality, security, and availability of health information
  2. The HIM dept monitors
    • quality of patient info
    • ensures info is maintained and protected according to regulations
  3. HIM most important function
    Storage and retrieval of patient information
  4. HIM typically manages the following services
    • Record processing
    • Monitioring of record copletion
    • Transcription
    • Release of patient information
    • Clinical coding
  5. 2 types of Transcription
    • Textual--What is written
    • Contextual-- What is interpreted
  6. HIM typically manages the following functions
    • Research and statistics
    • Cancer and/or trauma registries
    • Birth Cert. completion
  7. This is implemented to determine what work and what doesn't. And what needs to be changed
    Workflow Analysis
  8. These were established  to mirror the any processes and uses of the electronic health record
    Work Queues
  9. Examples of work queues
    • Quality Review
    • "Loose Sheets" queues
    • Birth Certificate queues
    • Medical Coding queues
  10. Name for lab and x-ray coding
    Ancillary Coding
  11. EDMS
    Electronic Document Management System
  12. These are considered the most fundamental responsibilities of most HIM depts
    • Storage and Retrieval
    • Record Processing
    • Record Completion
    • Treanscription
    • Release of Information
    • Clinical Coding
  13. 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
  14. Most important index used by HIM
    Master Patient Index
  15. This functions as the primary guide to locating pertinent demographic data about the patient and his or her health record number
    Master Patient Index
  16. Basic Information of the Master Patient Index
    • Last, First and Middle Name
    • Health Record Number
    • Date of Birth
    • Gender
    • Dates of Encounter
  17. R-ADT
    Registration, Admission,Discharge, Transfer System

    AKA--Patient Registration System
  18. Benefits of the R-ADT
    Ability to access data by ore than one individual at a time
  19. This permits the use of several search tecniques for locating an existing patient's information
    Electronic MPI
  20. What is some major concerns of a Manual MPI
    • Misfiled Cards
    • Only one person at a time can access the index
  21. Name
  22. Name some errors that both manual and electronic MPI can contain
    • Misspellings
    • Incorrect demographic data
    • Transposition of Nubers
    • Typographical Errors
  23. 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
  24. The most common MPI errors occur when
  25. At the point of registration when existing MPI info is not located
  26. 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
  27. This is where a patient is assigned another person's medical record number

    What is the possible outcome

    The medical information of two or more individuals are combined, resulting in problems identifying what medical information belongs to which patient
  28. This is when one or more medical record numbers exists for the same patient.

    Mostly occur where

    • Occurs in multiple facilities--Multi-hospital systems
    •                                          Health Info Exchanges
  29. EMPI
    Enterprise Master Person/Patient Index
  30. This is when 2 different MPI's combine and make 1 huge system
    EMPI (Enterprise Master Person/Patient Index
  31. 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
  32. 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)
  33. This number identifies not only the patient, but also the patient's record
    Health Record Number
  34. This type of idenification should not be used as patient identifiers
    Social Security Numbers
  35. Name the identification systems used for Paper-based health records
    • Serial Numbering
    • Serial Unit Numbering System
    • Alphabetic Identification and Numbering System
  36. 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
  37. 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
  38. 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
  39. What is the advantage of the Unit Numbering System
    All the information, regardless of the number of encounters can be filed or linked together
  40. The Unit Numbering System works best in what environment
  41. 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
  42. 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
  43. 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
  44. 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
  45. All forms should
    Contain a unique identifier
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