Medical Records Procedure Manual

Describe the responsibility of the medical office specialist to protect all protected health information (PHI).

The American Health Information Management Association (AHIMA) is a recognized, respected association of health information management (HIM) professionals worldwide. Founded in 1928, AHIMA has become a respected authority for professional education and training in the effective management of health data and medical records needed to deliver quality healthcare to the public. Throughout AHIMA’s history back to 1928, the American College of Surgeons established the Association of Record Librarians of North America (ARNLA) to “elevate the standards of clinical records in hospitals and other medical institutions” (www.ahima.org, 2015). Since its formation, the Association has undergone several name changes in its evolution of the profession. In 1938 the Association changed its name to the American Association of Medical Record Librarians (AAMRL) for a more concise representation. When the Association became the American Medical Record Association in 1970, health information professionals had increased their involvement in hospitals, community health centers, and other health service facilities. As the health industry continues to evolve, the Association changed its name in 1991 to American Health Information Management Association to capture the expanded scope of clinical data beyond medical records to health information comprising the entire continuum of care.

While I was looking over the Health Current Toolkit information, I was very impressed on how they covered just about everything. One of my favorite things that I found was the frequently asked questions page, for me it was very helpful because this is all new to me and this page was extremely helpful to understand the basics about HIE records. I feel that the whole thing had all the details you needed to understand what they were and how they worked. The only thing that was not too clear for me was that they are able to access your all your records in the case of an emergency. I am all for that because in an emergency, I want all my records available to receive the best care, however what is classified as an emergency and are there a

In 1988, an information system called the Composite Health Care System (CHCS) was formulated by a company called Science Applications International Corporations (SAIC). Science Application International Corporations won the contract worth $1.02 billion from the Military Health System to design, develop and implement CHCS. Although CHCS information system was designed in 1988, it wasn’t until 1993 that the system was introduced. Since 1993, CHCS has become the biggest medical information system for the military medial facilities. CHCS is the most essential part for the Department of Defense (DoD) for inpatient and outpatient. The system supports 143 military installation worldwide, 1,100 military clinics, and produce thousands of daily

Health Information Exchange (HIE) supports both transferring and sharing of health related information that is usually stored in multiple organizations, while maintaining the context and integrity of the information being exchanged (HIE, 2014). The goal of health information exchange is to expedite access to and retrieve clinical data to provide safe efficient, effective, equitable, timelier patient-centered care (HIE, 2014). HIE “provides access and retrieval of patient information to authorized users in order to provide safe, efficient, effective, and timely patient care” (HIE, 2014).

Unfortunately, with five medication aides and two managers all doing filing, records often get misplaced, whether they are put in the wrong section of the expand-a-file, filed under the wrong section of a resident’s binder or accidently get deposited into the secure shredding container. The implementation of a new health documentation system would be a marked improvement to the current system.

It assists the Doctors with the correct and updated medical and health records of the patient. All records will be easily and safely transferable from one health care provider to another as necessary. Patient can access his/her medical and health records online. With that being said, HIE eliminates a patient from needing to run from one doctor to another for paperwork and signature. It decreases the chances of a doctor giving the patient the wrong dose of medicine. It removes the chances that the nurse could misread what prescription the doctor wrote. HIE is a very smart way to properly manage an individual’s EMR and EHR.

Any patient that is seen by a physician within the United States is to be protected by the “Health Insurance Portability and Accountability Act” or HIPAA, which was passed into law in 1996 (Jani, 2009). All health care facilities dealing with any protected health information (PHI) are to ensure that all physical/electronic processes are safeguarded from any third party entity or unauthorized personnel according to HIPAA. All health care data to include any medical insurance

HIE face a range of challenges as they try to get hundreds and even thousands of participants in sharing data. Getting data in front of doctors and other clinicians is one of the biggest challenges HIEs face. Ideally, it would be delivered directly to a providers' EMR system, so when a patient goes to an outside lab for blood tests, the results would show up in the electronic record at the doctor's office, and the doctor would be notified that the results are there. However, with limited EMR use across the country, HIEs have had to provide alternative delivery methods. HIE is considered to be one of the key components of the national health IT infrastructure being established by the HITECH Act. Policymakers and health care providers believe this health IT infrastructure will produce a number of benefits, many of which are directly related to HIE.

Health Information Exchange is the electronic movement of healthcare information amongst organizations according to the national standards. HIE as it is widely known, serves the purpose of providing a safe, timely, and efficient way of accessing or retrieving patient clinical data. Health Information Exchange allows for doctors, nurses, pharmacists, and other vital healthcare professionals to have appropriate access and securely share vital medical information regarding patient care. Health Information Exchange has been in efforts of developing for over 20 years in the United States. In 1990 the Community Health Management Information Systems (CHMIS) program was formed by the Hartford Foundation to foster a development of a centralized data repository in seven different geographically defined communities. Many of the communities struggled in securing a cost-effective technology with interoperable data sources and gaining political support. In the mid-1990s a similar initiative began known as the Community Health Information Networks (CHINs) with the intention of sharing data between providers in a more cost-effective manner. In 2004, the Agency for Healthcare Quality and Research Health Information Technology Portfolio was funded $166 million in grants and contracts to improve the quality and safety to support more patient-centered care. This was the beginning of the progress we have seen in HIE today. Health Information Exchange devolvement serves the purpose of improving

The Health information exchange or also known as HIE is the sending of healthcare-related data electronically to facilities, health information organizations and government agencies according to national standards. The goal is to be able to access and retrieve data more efficient, safer, and to improve the quality of care and patient safety and reduce healthcare costs.

Communication is the key to relating in all environments. When communication lines are broken, it makes take in jobs and personal relationship suffer. In medical environment communication is key in running hospital, nursing home and community care providers. With technology our communication has advanced because now we have electronic medical records. Electronic medical records are a way of providing the medical staff and insurance on the patient health information and insurance coverage. As stated by About.com, “This also provide the doctors away to for individual patients, access to good care becomes easier and safer when

Health information management involves the practice of maintaining and taking care of health records in hospitals, health insurance companies and other health institutions, by the use of electronic means (McWay 176). Storage of medical information is carried out by health information management and HIT professionals using information systems that suit the needs of these institutions. This paper answers four major questions concerning health information systems.

Case management in the emergency department, constantly works to find the right data in a patient’s record to ensure that they have the correct insurance coverage and can be admitted or discharged at the appropriate time and place. Even when the smallest amount of essential information is not documented, this otherwise straight forward process turns into a scavenger hunt for who has seen the patient, interventions that were done and for what reasons, and at what time all of these things took place. ED case manager Veronica Kountz (personal communication, March 20, 2015) states that the inadequacy of documentation can lead to insurance companies not covering patient costs, which the hospital then has to absorb. Before a patient can be admitted or discharged, the right

Information technology use in HMHP has been implemented in the past few years. The organization as a whole has gone to a system called EPIC that was at first difficult for staff to get used to but now is an asset to the organization. Advances in information technology have introduced new design approaches that support health care delivery and patient education (Demiris et al., 2008). The electronic medication administration record has made it safer for patients when receiving medications in the hospital because of the checks it uses upon administration. Also, the double verification of medication like heparin and insulin help to reduce errors. Physicians entering their own orders and having electronic notes has also made it easier to carry out orders and know what the plan entails. Information technology has also