Health Information Personnel

What do health information management (HIM) professionals do?

work to acquire, analyze, and protect digital and traditional health information that is considered vital to the delivery of quality patient care

How is HIM at the heart of healthcare?

Health records and health information systems serve as the backbone of healthcare systems, hospitals, clinics, and healthcare provider offices

What does the patient's health record or chart include?

the patient’s medical history

results of physical examinations

results of X-ray and laboratory tests

diagnoses

treatment plans

doctors’ orders and notes

nurses’ notes

What does the health record show?

the diagnosis and treatment plan

the patient’s symptoms and response to treatment

What are the uses for health records?

Provide background and documentation for insurance claims and Medicare reimbursement

legal actions

professional review of treatment

Research and planning

Provide data for clinical studies

evaluations of benefits and costs of medical and surgical procedures

assessments of community health needs

What do electronic health records (EHRs) do?

Broadens and alters the job responsibilities of health information management professionals

What must HIM professionals do?

Use EHR software to maintain data on patient safety, patterns of disease, disease treatment and outcomes, and conduct clinical research

What do Health Information Administrators direct and control?

the activities of the Health Information Department

Who do Health Information Administrators train and supervise?

the health information staff

What do Health Information Administrators develop systems for?

Develop systems for documenting, storing, and retrieving health information

What do Health Information Administrators manage?

workflow for capturing data in a variety of healthcare settings, from large hospital systems to small physician practices

What do Health Information administrators organize, maintain, and disclose?

Content considered part of the patient’s health record

What may some Health Information Administrators testify about in court?

patient health records and procedures of record keeping

What do Health Information Administrators focus on and work towards?

Operations management

ensuring accurate and complete health records and cost-effective information processing

What do Health Information Administrators work with a team for?

to employ security measures such as authentication and permission protocols, encryption, and damage prevention techniques

What do Clinical Documentation Improvement (CDI) specialists review?

patient’s electronic health record and serve as liaison to the clinical treatment team in documenting clinical care

What do Clinical Documentation Improvement (CDI) specialists work to obtain?

Appropriate clinical documentation to ensure that level of service rendered and clinical complexity of patient’s condition is completely and accurately documented

What do some health information administrators specialize in?

protecting the confidentiality of health information, serving as privacy officers

For the health information administrators who choose to specialize as a health data analyst, what do they do?

Work to acquire, manage, analyze, interpret, and transform data into accurate, consistent, and timely information

What is the minimum educational requirement for a registered health information administrator?

a bachelor’s degree in health information administration

What credential does the American Health Information Management Association (AHIMA) offer?

Registered Health Information Administrator (RHIA)

What are health information technicians also referred to as?

Coders

What do Health information Technicians interact with physicians and other healthcare professionals for?

to maintain complete and accurate health information and records

What do Health Information Technicians use?

Classification software to assign clinical codes to each diagnosis and procedure, relying on knowledge of disease processes and multiple classification systems, such as CPT and ICD-10

What do DRGs stand for?

Diagnostic Related Groups

What does the DRG determine?

the amount for which Medicare or other insurance programs using the DRG system will reimburse the healthcare provider if the patient is covered

What may some Health Information Technicians advance to?

the position of DRG Validator

What do DRG Validators do?

Perform quality review of records and data coded by the coding staff

What may Health Information Technicians specialize as?

Quality improvement analysts

Cancer registrars

Electronic health record support specialist

Who do employers of health information technicians favor?

technicians who have become a registered health information technicians (RHIT)

How do Health Information technicians become a Registered Health Information Technician (RHIT)?

must pass a written examination offered by the American Health Information Management Association (AHIMA)

What certifications can a health information technician acquire?

Certified Coding Associate (CCA)

Certified Coding Specialist (CCS)

Coding Professional (CCP)

Where did health information technicians earn the most?

Management companies and enterprises

What do medical transcriptionists do?

translate and edit voice recordings made by physicians and other healthcare providers regarding patient assessment and treatment

What do medical transcriptionists transcribe?

Transcribe a variety of medical reports, including reports about emergency room visits, diagnostic imaging studies, operations, chart reviews, and final summaries

What two voluntary designations does the AHDI award medical transcriptionists?

Registered Healthcare Documentation Specialist (RHDS)

Certified Healthcare Documentation Specialist (CHDS)

How often do RHDSs and CHDSs have to recertify?

must earn continuing education credits every three years to be recertified

What is essential when seeking work as a medical transcriptionist?

Understanding medical terminology

Are jobs expected to increase or decline for medical transcriptionists?

Decline (2%)

Where did medical transcriptionists earn the most?

Hospitals

What is the educational requirement for medical transcriptionists?

Employers prefer those who have completed postsecondary training or an associate degree

What do medical librarians provide?

information about new clinical trials and medical treatments and procedures

teach medical students how to locate medical information

answer consumers’ health questions

How much is the employment of medical librarians expected to grow?

5%

Where may Medical librarians work?

School and academic libraries

Public and special libraries

Hospitals

Religious organizations

Government agencies

What may Entrepreneurial librarians start?

Their own consulting practices