The Nightingale Hospital Next Joint Commission Inspection.

Information Management has to do with capturing information, efficient planning, organizing and evaluating the information to interpret for an organization to make well informed decisions. (Hinton, 2006) The main reason organizations depend on information is to improve its overall management in

It is no secret that the medical profession deals with some of population’s most valuable records; their health information. Not so long ago there was only one method of keeping medical records and this was utilizing paper charts. These charts, although still used in many practices today, have slowly been replaced by a more advanced method; electronic medical records or EMR’s. “The manner in which information is currently employed in healthcare is highly inefficient, which slows down communication and can, as a result, reduce the emergence and

The Clinical Documentation Improvement (CDI) has emerged as the most vital drive for overcoming the issues associated with maintaining a complete and good sound medical record in the U.S healthcare system. The main focus of CDI is to enhance clinical clarity of the health records which usually involves the process of improving the medical/health records documentation in order to promote effective patient outcome, data quality measures and accurate reimbursement for services and care rendered. For a medical record to be meaningful and mirror the scope of treatment and services provided, it must be accurate and meet the established guidelines set forth by the governing bodies such as the Centers for Medicare and Medicare.

Updating and maintaining the accuracy of records and reports is vitally important for any care setting. The information in records or reports could be about an individual who is being cared for in our workplace, a relative or friend, or it could be about the organisation itself, about of for someone who works there, or for administrative purposes. The information could come to us in different ways: verbally- in a conversation or on the phone; on paper- in a letter, an individual’s health record, instructions from a health

The hospital’s plan for information management encompasses the full spectrum of data generated and used by the organization in all various departments from housekeeping, laundry services, imaging, and pharmacy through to nursing. In order to provide cost-effective quality services, information must be accurate and communication of the information should be securely transmitted in a timely manner to the appropriate individuals on a need to know basis.

Information Management is one of the organizational management chapters in the JACHO Accreditation Manual for Hospitals. According to this document, organizations must have well-developed processes for managing of patient data, including, but not limited to, initial recording, retrieving, reporting, and displaying of all patient-related information associated with specific patient care activities1.

Medical record keeping has a robust history of promoting patient care. The patient’s need for optimal

2. Provide a single, shareable, up to date, accurate, rapidly retrievable source of information, potentially available anywhere at any time (Electronic Medical Records, 2005).

There are many types of data collected, such as, Demographic, financial, socioeconomic, and clinical data are collected from patients so that the healthcare providers of services to the patient are able to assess the history of whatever disease the patients is suffering from and how is to be treated. Data collection in the facility is well organized in a way that promotes shared assessment, treatment and communication. Nurses and front row staffs collects raw data’s from the patient, and. The Heath Information Manager and team are the facility are responsible in analyzing and presenting the data collected in a meaning and easily understandable way to served the specific purposes for which it was collected. Examples of such data are, patient’s name, height, weight, gender, allergies, and third party

responsibilities and duties in maintaining the records to meet needs of health care stakeholders. Abuse

Health information management professionals ensure that patient information under a provider’s care is correct, complete, and safe (Gartee, 2011). Patient health information is sensitive and must be handled only by trained professionals with experience in the field. HIM professionals such as the Registered Health Information Administrators manage employees in the HIM department that work with patient information. Registered Health Information Administrators must “Possesses comprehensive knowledge of medical, administrative, ethical and legal requirements and standards related to healthcare delivery and the privacy of protected patient information” (“RHIA”, 2015), In addition, the RHIA role is actively involved with the forms control process and involved with all units that utilize patient information in any way (Gartee, 2011).

Information Management is the collection and management of information from one or more sources and the distribution of that information to one or more audiences.

Information governance is divided into 8 key principles: Accountability, transparency, integrity, protection, compliance, availability, retention, disposition. Now that hospitals are more focused on applying electronic health record systems (EHR) the more information governance will be required when applying to the eight key principles (Davoudi, 2015, p. 1). According to Davoudi (2015), “Information governance provides for the other data-given in AHIMA’s HIM Core Model by providing parameters based on organizational and compliance policies, processes, decision rights and responsibilities” (p. 2).

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.

Information management (IM) is the collection and management of information from one or more sources and the distribution of that information to one or more audiences; is also particularly critical to businesses that work in conjunction with other businesses, so the two must share information with, or transfer information to, each other. In addition, businesses with more than one department or unit can use the MIS to compile information in one central location, thereby preventing information loss.