Health Information Management: Practices, Regulations, and Career Opportunities, Exams of Nursing

Download Health Information Management: Practices, Regulations, and Career Opportunities and more Exams Nursing in PDF only on Docsity! HIM - Health Information Management Health Information Management (HIM) - HIM is the practice of acquiring, analyzing, and protecting digital and traditional medical information vital to providing quality patient care; Recognized as an allied health profession since 1928; provides management, organization, analysis, and control of health information. HIM Trends & Topics - The implementation of ICD-10-CM/PCS and training; Privacy and Security: AHIMA has a myriad of resources addressing privacy, security and confidentiality; Electronic Health Records; Clinical Documentation Improvement All HIM Associations - AHIMA : American Helth Information Management Association; NYHIMA: NY Health Information Management Association; LIHIMA: Long Island Health Information Management Association; GNYHA: Greater NY Hospital Association; AMA: American Medical Association; CMS_ Centers for Medicare and Medicaid Services; WHO: World Health Organization; Health Insurance Portability & Accountability Act (HIPAA) - !996, is a set of rules that doctors, hospitals, and other health care providers must fllow to help ensure that all medical records, medical billing and patient accounts meet certain consistent standars with regard to documentation, handling and privacy. In addition, it requires that all patients be able to access their own medical records, correct errors or omissions and be informed about how personal information is shared or used and about privacy procedures. Business Associate - Any person or organization that performs work on behalf of or provides services to the covered entity where PHI is or is likely to be used or shared; generally, a contractor or vendor of the covered entity Business associate Agreement (BAA) - An agreement between the covered entity and the business associate will comply with HIPAA and our expectations Covered Entity (CE) - Are the companies and their employees: Health Plans, Health providers, Dental, Vision, Prescription, HMO's, Commercial, Government, Employer (sponsored group helth plans) Federal HIPAA/Health Insurance Portability & Accountability Act rules vs State Law - NY State Law overrides Federal HIPAA rule with regards to the releasing of psycho therapy notes examples of a patient identifier (PHI) - Name, SS#, DOB, All geographic subdivision(street address, city, county, precinct, zip code, other equivalent geocodes) all elements of dates(except year) telephone & fax numbers, email address, medical record numbers, health plan beneficiary number (medicaid/medicare/health insurance #), account numbers, certificate/license #'s, vehicle identifiers and serial #'s, biometric identifiers (voice/finger print and eye scan), full face photo image and any other unique identifying number, charcteristic or code. authorization - a medical release; written statement by the patient or legal representative giving permission to release their PHI;The process of giving someone permission to do or have something A Health Care Proxy - a legal document which a patient appoints an agent to healthcare decisions on their behalf Privacy Notice - A written explanation of how the company handles and shares your personal financial information. letter of representation - a written communication from the client to the auditor formalizing statements that the client has made about matters pertinent to the audit HIPAA - patient can have assess - a chronological record of a patient's medical history and care that includes information that the patient provides, as well as the physician's assessment, diagnosis, and treatment plan List the paper work that consists in a Medical Record (parts of the Medical Record) - Patient Information Form, Medical Hidtory (Hx), Physical Exam (PE), Consent Form, Informed Consent Form, Physician's Orders, Nurse'e Notes, Physician'sProgress Notes, Consultation Report, Ancillary/Miscellaneous Reports, Diagnostic Tests/Laboratory Reports, Operative Report, Anesthesiology Report, Pathology Report, DIscharge Summary Query (Queries) - when you have to go back to doctor for clarification on a medical record so it can be coded properly. Must submit request form Operative report (OR) - Documents must be completed by the Attending Physician and surgery is done xitems that are required on a discharge summary - Patient Name, Medical Record Number, Date of Birth, Admission Date, Discharge Date, Attending Physician, Dictating Physician, Reason for Hospitalization, Principal Diagnosis, Secondary Diagnosis, Pertinent History of Present Illness, Pertinent Findings of Physical Examination, Pertinent Past Medical History, Pertinent Past Surgical History, Pertinent Family History, Allergies, Pertinent Laboratory Data, Pertinent Radiology Data, Hospital Course, Procedures Performed; Instructions and Condition on Discharge: Physical Actvity Limitation, Medications, Diet, Follow-up Care; Final Diagnosis, Disposition time frame when the surgeon completes an operative report - immediately after surgery items maintained in a MPI - Internal patient identification, Patient name, DOB, Gender, Race, Ethnicity, Alias/previous name, SSN, Address, Facility ID, Universal Patient Identifier, Account #, Admission Date, Discharge Date, Service Type, Patient Disposition, alongside the patient's medical history Medical Record number (MR#) comes first if you are sorting terminal digit order - the third numbers are the primary number Multiple job opportunities available in HIM (Health Information Management) Health care Field other than coding & billing - Management, (HIM) Medical Records, Tumor Registry, Trauma Registry (ER), Transcription, Quality Improvement, Release of Information, Patient Admissions, Compliance Auditor, Physician Accreditation, Utilization Review, Physician Offices, Risk Management, Consulting Firms, Government Agencies, Law Firms, Insurance Companies, Correctional Facilities, Extended Care Facilities, Pharmaceutical Research: Statistician, Clinical Trials Coordinator, Data Manager; Information Technology: System Analyst, Project Manager, Data Manager; Medical Software Companies: Software Designer, Software Tester, Health Information Manager, Clinical Data Specialist, Patient Information Coordinator, Data Quality Manager, Data Resource Administrator, Research and Decision Support Analyst, Security Officer AHIMA - American Health Information Management Association - is the leading voice of health information. They are a professional association of health professionals involved in the HIM needed to deliver quality health care to the public AMA - American Medical Association produces codes of medical ethicsfor clinicians and resposible for the publishing of coding books AMBA - American Medical Billing Association - offers the Certified Medical Reimbursent Specialist (CMRS) exam BA - Business Associate - any person or organization that performs work on behalf of or provides services to the covered entity where PHI is or is likely to be used or shared; generally, a contractor or vendor of the covered entity; anyone who is not an employee, ie contractors, consultants BAA - Business Associate Agreement - an agreement between the covered entity and the business associate will comply with HIPAA and their expectations CCA - Certified Coding Associate CCS - Certified Coding Specialist CCS-P - Certified Coding Specialist - Physician Based CE - Covered Entities - any employee who is hired by a hospital CMRS - Certified Medical Reimbursement Specialist CMS - Centers for Medicare and Medicaid Services - responsible for administering Medicare and overseeing states' administration of Medicaid; formerly known as the Health Care Financing Administration DOH - Department of Health Dx - diagnosis HHS -