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Health information management (HIM)
assemble and organize a patients health information to create a medical record. Includes a medical history and family medical history
Medical history
lists all diseases and symptoms a patient has had or their current symptoms, results of examinations and diagnostics test, treatments and other health services
Medical record
contains personal identifying information to connect a patient to the right record
personal identifying information
Social security number
HIM Employees
work with health records, files, histories, protection of health information
Heath Information Technicians
People who work in the field of health information management who specialize in specific kinds of information or data such as cancer registry or data collection
Medical coders
Identifies the diagnoses, procedures, and services provided in a patient's health care record and assigns specific codes to each
Registered Health Information Administrator
Manages patients health information and medical records, RHIA
Registered Health Information Technician
Ensures that medical records are complete, accurate, and entered in the correct format, RHIT
Certified Coding Associate
Qualified to code in both hospitals and physician practices, CCA
Certified Coding Specialist
skilled in doing patient medical record data in the hospital setting, CCS
Health Information Technology
focuses on the systems that are used to manage health information and the secure exchange of health information in a digital format, HIT
Health Informatics
Design and develop information systems that improve the quality and efficiency of patient care
medical informatics
Based on physician research
Nursing informatics
focuses on clinical research and attracts nursing students
Public Heath informatics
Includes public Heath and bio surveillance (tracking diseases, patterns and threats to human health, etc)
Applied informatics
examines how medical information moves in an electronic environment. It studies processes, policies, and technological solutions.
Medical assistants
-Work in a medical office for physicians, chiropractors, etc.
- keep office running smoothly
-complete a 1-2 yr training which includes and internship
-interns spend time at a healthcare facility and apply the skills they learned in school
-experienced assistants can eventually advance to other occupations (nursing, etc)
Health ducators
-at least have a bachelor degree
-educate patients about their diagnosis
-help patients use info to prevent illness and manage chronic conditions
Interdisciplinary Healthcare Team
a group of professionals from different health science training backgrounds working in coordination toward a common goal for the patient
Technical skills
-the ability to perform tasks in a specific discipline or department
-Examples:
1. MA takes a patients medical history
2. Physician uses the medical history to determine a diagnosis
3. Medical lab technician records lab results
Business Letter
-no unnecessary words to avoid wasting the patients time
-accurate and complete information to avoid mistakes and misunderstandings
-used Block Style Format and Standard English
-local organization to avoid confusing the reader
Clinical Information
Begins with medical history, health medical
Conditions
Personal information
Information that can personally identify someone, such as their name, email address or billing information,
Employability skills
professionalism, effective communication, ethical behavior, academic preparation, critical thinking, problem solving, and teamwork
Career portfolio
-a written record of career planning and preparation
- includes an essay, resume, letters of recommendation, work, health certifications, activities, community activities