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OPC Unit 1 HIM 1.2 HIM and the Medical Record

Health Information Management (HIM) involves acquiring, analyzing, and protecting medical information essential for quality patient care. Health Information Managers oversee data management, ensuring privacy, compliance, and accessibility of patient records for clinical use and funding purposes. The medical record serves multiple functions, including clinical documentation, funding, and legal evidence, facilitating communication among healthcare professionals and supporting patient care continuity.

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OPC Unit 1 HIM 1.2 HIM and the Medical Record

Health Information Management (HIM) involves acquiring, analyzing, and protecting medical information essential for quality patient care. Health Information Managers oversee data management, ensuring privacy, compliance, and accessibility of patient records for clinical use and funding purposes. The medical record serves multiple functions, including clinical documentation, funding, and legal evidence, facilitating communication among healthcare professionals and supporting patient care continuity.

Uploaded by

6vxpfdr5vy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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Health Information

Management : HIM & the


Medical Record
Group 1: Scott Grentell
Group 2: Dreda Heard
Health Information Managment

What is Health Information Management?

(it) ‘is the practice of acquiring, analysing and protecting digital and traditional

medical information vital to providing quality patient care.’ – (AHIMA, 2020)


The Medical Record

“Clinical record keeping is an integral component of


good professional practice and the delivery of quality
healthcare and enable continuity of care…and enhance
communication between different health care
professionals” Mathioudakis et al 2016
Health Information Managers

“Health Information Managers are the business


managers and custodians of data and information
and health care…they are experts in managing
data and processes in an information system”
Zeng, Reynolds & Sharp 2009
Record Oversight
•Safeguard and preserve privacy of patient information irrespective of the storage mechanisms
Privacy & •Respond to patient requests to exercise their privacy rights
Confidentiality •Ensure compliance with regulatory bodies, legislation and organisational policy as they relate to privacy
•Protect the confidentiality of all information obtained in the course of professional service

•Comply with information release legislations


•Only release information with valid authorisation from a patient or person legally authorised to consent o
Release behalf of a patient
•Comply with release of information with correct authorisation from federal or state bodies
•Disclose only information that is directly relevant to the achieve the purpose of disclosure

•Implement standards, policies and procedures related to access and amendment


Access •Release and disclose of identifiable and non-identifiable health information in response to current laws,
regulations and governing organisational standards/policies
Record Oversight

As the stewards of patient information, our responsibilities for information are


• the protection of information
• to ensure accessibility for clinical care
• to facilitate the availability of patient information at the point of care, and
• to support the availability for analysis to support clinical decisions and service development
Record Oversight

In terms of funding we are responsible for ensuring utility of the information for
• Data extraction
• Reporting
• Informing funding

The sources of this information for which we are stewards are many and varied.
Contents of the Medical Record
End Uses of the Record

Primary Use – Clinical DocumentationSummarises


– Doctors, Nurses & Allied Health
care and follow up
Communication of Critical Record of care provided in an Primary Tool for transfer of care
actions on the Discharge
Clinical Information episode of care to the community
Summary

Secondary Use – Funding


Clinical Coding – ICD10AM
& Research- Clinical Coders, Service Planners
Drives WIES funding through
Internal & External Audit, Informs service planning,
Diagnosis Codes & ACHI grouping to Diagnostic Related
Documentation Education development and research
Procedure Codes Groups

Tertiary Use – Legal – Patients, Coroners Court other Legal Entities


Legal document containing details of care
Accessed by the patient/patient Patients enrolled in MyEHR or Patient
provided across time, interventions
representative via FOI requests &/or Portals will have access to specific
received, outcomes and clinicians
subpoena documents within their medical record
communication
This completes the Medical Record Topic Learning Area Topic

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