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Health Information Management (HIM)

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Health Information Management (HIM) is the process of protecting, analyzing, inspecting and acquiring medical information such as health records, each time a patient is seen by a healthcare provider. The HIM professional is an important connection between doctors, nurses, patients, insurance companies and everyone in the medical field. Every time a healthcare professional sees and treats a patient, they record what they observed, how the patient was treated medically, and future steps in the treatment plan discussed between the patient and the healthcare worker. The medical record includes the patient’s symptoms, medical history that includes past, present, and family history, results of studies, such as x-ray reports, or lab results, diagnosis, …show more content…

Since Electronic health records were discovered, providers were able to make better decisions, provide quality care, and reduce medical errors by improving the accuracy of medical records. The number of patients and visits to medical offices and ERs have increased exponentially since 1900s. Technology now days have helped millions of doctors to provide more efficient care to their patients by having access to previous medical records. AHIMA’s mission is improve healthcare by advancing best practices and standards for health information management. Their mission also includes to be a trusted source of information for further education and future …show more content…

The patient is diagnosed with HIV/AIDS after having numerous blood tests and a kidney scan performed. After evaluation, treatment and determining the diagnosis of his condition, he will be discharged in three days. All of his health records must be stored, protected and only authorized personnel should have an access to his confidential records. His confidential health records may consist of demographics, diagnosis, medical history, medication list, blood test results, kidney scan results, treatment, plan of care and discharge summary. HIM professionals constantly try to ensure the patient records are accurate and complete so mistakes can be avoided. As more healthcare settings adopt electronic health records, physicians will have greater access to patient information, which will contribute to better outcome of patient’s

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Kaiser Permanente has been equipped since 2007 with Health Connect; which is the largest private electronic health record implementation in the world. This is a highly sophisticated electronic program that integrates inpatient, outpatient, and clinic medical records with appointments, registration, pharmacy, and billing for all kaiser members. In addition, this electronic program includes an entire medical library with a whole set of care support tools which are accessible to doctors, nursing staff and patients (Kaiser Permanente, n.d.). At kaiser permanente; nurses are expected to print out “the after-visit summary” (AVS), which contain the doctor recommendations for each patient that we see.

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The healthcare industry generates a great amount of data every day, as a form of record keeping, patient care, compliance, and regulatory requirements. Just a decade ago, all this data was stored in the form of hard copy form, now it is rapidly transforming to digital data which is called EMR (Electronic Medical Record). The digitalization of the healthcare has not just reduced cost of care, but also improved quality of care due to the abundance data that organizations receive from the EMR to identify the flaws in their system. I work in the healthcare industry where improving quality of care is our primary goal. We use software called eCW , which is an integrated system.

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Electronic health record (EHR) system transformed the health care system from a paper based industry to one that uses clinical information to provide higher quality of care to the patients by providers. Electronic medical records have many benefits in clinical, organizational and societal outcomes. Clinical outcomes includes improvements in the quality of care and reduction of medical errors. Organizational outcomes include, financial and operational performance as well as higher satisfaction among patients and clinicians. Societal outcomes include, conduct research and attain improved population health.

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Health Information Exchange Providers across the U.S. are turning to the Health Information Exchange also known as HIE. HIE provides secure online access to patients charts among a network of providers, hospitals, clinics, doctor’s offices, and pharmacies who join in the exchange, so they can have timely electronic access to records their patients will allow them to share. For patients this means having their medical records available no matter where they go and for providers it means having instant access to life saving information when seconds count

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The resources above expanded on knowledge concerning the definition, evolution, proposed outcomes, research and the technology of meaningful use of the electronic health record. Nursing administrators, staff nurses, and nursing informaticists all perform an essential role in achieving meaningful use of the electronic medical record to improve patient care. Certain authors referenced other authors proving that the health information technology field is indeed a tightknit community. The resources were well written from highly credentialed authors and were, for the most part, easy to comprehend. All of these articles were written for the nursing professional with the exception of resource

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In her assessment of the American Reinvestment & Recovery Act (ARRA), Murphy (2009) discusses how its enactment provided unprecedented funding for the advancement of health information technology (HIT) which served to promote health care reform. Electronic health records (EHRs) by extension received a boost via incentivization for appropriate use in hospitals and ambulatory settings (Murphy, 2009). The benefits of EHRs include the ability to improve the delivery and quality of nursing care, the ability to make more timely and efficient nursing care decisions for nursing, the ability to avoid errors that might harm patients and the ability to promote health and wellness for the patients (McGonigle & Mastrian, 2015). An appropriate use of EHR

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EHR has its advantages and disadvantages of implementing new technology in the health care system, EHR can help improve collaboration, communication, performance, and decrease added work. The author believes that the incentives that the government is providing for physicians and hospitals to adopt electronic health records system will help improve accessibility to patient data, improve preventative health, and provide a collaboration from both patients and health professionals to increase patient ’s outcomes of their overall

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As records were shared electronically rules were implemented for clinicians to follow known as The Health Insurance Portability and Accountability Act (HIPAA) of 1996 (Summary of the HIPAA Security Rule ,2013). These rules were implemented for clinicians to protect the

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Compliance with Health Information Management Laws and Regulations Introduction Privacy and confidentiality are the fundamental aspects of health information management. The most important thing in health information management is the assurance to patients that the information they share with health professionals shall be maintained with confidentiality ("HIM Functions in Healthcare Quality and Patient Safety", 2018). The absence of such assurances increases the likelihood of patients withholding critical information. Withholding of information in health management may lead to detrimental effects which include adverse effects on the quality, safety as well as the outcome of care. Due to the high level of risk associated with health information,

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Even though EHR’s are very effective and beneficial, some health organizations continue to use paper records. The reason: high costs and challenging and prolonged process of implementing (Thakkar & Davis, 2006). This paper will briefly discuss the benefits, costs, and struggles of implementing EHR systems. “The purpose of the EHR is to create a health care structure that will allow simultaneous access to patient information, and give the support to make best possible decisions” (Thakkar & Davis, 2006). EHR’s benefit patients and workers but most importantly improves the overall health system.

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This includes creating, managing and following patient data. The American Health Information Management Association (AHIMA) defines information governance as “an organization wide framework for managing information throughout its lifecycle and for supporting the organization’s strategy, operations, regulatory, legal, risk, and environmental requirements.” In today’s healthcare system, it is more important than ever to know and understand how healthcare information is created, transferred and used. Due to the development of systems such as electronic health records and clinical decision support systems it is important that health information maintains its reliability and validity throughout its

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I have gained knowledge about informatics. I have learned about the great importance of electronic medical records (EMR) to the current and future of patient charting and documentation. I have gain skills in how patient portals work, their purpose, as well as their importance to patient self-efficacy. My attitude has always been positive to the importance of informatics. I believe that change in health care can be difficult and very hard.

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The American Health Information Management Association is recognized for being the leading source of HIM knowledge. AHIMA was founded in 1928 and its certificate is considered harder to get compared to

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The development of the United States health care delivery system has significantly enhanced the methods of advanced medical technology, information management, and patient care for all health care professionals and society. Moreover, the United States health care delivery system is a unique system with many organizations and individuals that are involved in the delivery cycle. Health Care delivery organizations such as American Health Information Management Association is an established organization that supports and direct the needs of its health care professionals and patients. Organizational Selection and Background October 1928, Ms. Grace Whitney Myers and the American College of Surgeons created the Association of Record Librarians of North America (ARLNA) which later became known as American Health Information Management Association (AHIMA).

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My experience with electronic medical record (EMR) is great. As a nurse it helps me access relevant patient information with a click of a button and guarded me from making medical errors. According Mason, Leavitt and Chaffee (2014), electronic medical record (EMR) has shown to improve patient safety, enhance quality, reduce workloads, and improve care coordination. Moreover, it captures information from laboratory, pharmacy, radiology, and equipment, such as EKG, smart pumps and etc.

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