Health Information Management Overview

What is the purpose of an Electronic Health Record (EHR)?

To manage patient information including demographics, progress notes, medications, vital signs, past medical history, immunizations, lab data, and radiology data.

What must a Medicare medical record contain?

Information to justify the admission, support the diagnosis, and describe the patient's progress.

What is the Medical Patient Index (MPI)?

A critical document that maintains demographic information such as name, medical record number, patient name, gender, race, and SSN.

What is included in the History and Physical documentation?

Chief complaint, history of present illness, past medical history, family history, operative report, social history, physical examinations, impression or diagnosis with treatment plan, and ancillary reports.

What is the Chief Complaint in a medical record?

A statement made by the patient explaining why they came to be seen.

What is the significance of the Radiology Records?

They include the order generated, diagnosis of the sign/symptom, results of the procedure, and any special report documents related to the evaluation of treatment.

What does an Informed Consent form indicate?

That the patient has been informed of the procedures and has signed the consent form.

What coding system is used for diagnoses in health records?

ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification).

What is the Health Insurance Portability and Accountability Act (HIPAA)?

A law enacted in 1996 that ensures patient confidentiality and the protection of health information.

How are health records regarded legally?

Health records are considered legal documents.

What is the role of the facility regarding medical records?

The facility owns the medical record; it does not belong to the patient.

What is the purpose of Revenue Cycle Management in healthcare?

To manage the financial processes associated with patient care, including billing and collections.

What is included in Ancillary Reports?

All imaging studies, lab work, and pathology reports.

What is the CPT-4 coding system?

Current Procedural Terminology, fourth edition, used for coding procedures performed on patients.

What is the importance of the Physical Examination in a medical record?

It provides a detailed assessment of the patient's current health status.

What does the term 'Demographic level' refer to in health records?

It includes patient-specific information such as name, medical record number, gender, race, and SSN.

What is the significance of the 'Impression or diagnosis' in a medical record?

It summarizes the clinician's assessment and outlines the treatment plan.

What is the role of the Operative Report?

It documents the details of a surgical procedure performed on the patient.

What is the purpose of the Past Medical History (PMH) section?

To provide a record of the patient's previous health issues and treatments.

What is the role of the Social History in a medical record?

It documents relevant social factors that may affect the patient's health and treatment.