10 Responsibilities of Health Information Management

Ensuring Accuracy, Accessibility, and Privacy of Health Information

Health Information Management is the process of maintaining, storing and retrieving patient health information in accordance with applicable Federal, State, and accrediting agencies' requirements. There are 10 main responsibilities within the framework of health information management (HIM) that require specialized knowledge, skills, and abilities. Here is a brief summary of these ten responsibilities.

1
The Basics of Medical Coding

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Medical coding includes the correct assignment of medical codes for appropriate reimbursement by insurers and payers such as Medicare and Medicaid. It also means ensuring that all health records include proper diagnoses according to the ordered procedure. There are several sets of codes that coders use, and they must have up-to-date resources at hand as some codes change annually.

  • ICD-9 Codes
  • CPT Codes
  • HCPCS Codes
  • DRG (Diagnosis Related Groups)
  • Modifiers

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2
Medical Transcription

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Medical transcription refers to the accurate and timely transcription of dictated patient health information to make it accessible to authorized parties:

  • Patient medical history
  • Patient physical reports
  • Physician consultation reports
  • Patient discharge summaries
  • Radiology reports
  • Operative reports

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3
Medical Necessity

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Medical necessity refers to the reasonable and necessary treatment, procedures or services of an illness. Most insurers, including Medicare and Medicaid, will not pay for treatment that is not considered medically necessary based on standards of care.

4
Medical Staff Support

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A large portion of health information management is providing information to physicians about the patients being treated by them as requested. It also includes reviewing the records for compliance with state, federal and private insurance guidelines. After review, any weakness in compliance should be communicated back to the physicians and other clinicians to allow them to improve their documentation.

5
Assembly of Medical Records

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Each medical record should be assembled for the use in continuing health care by providing:

  • An accurate, legal record
  • Transcription of medical reports
  • Submission of information for reimbursement
  • Accessibility to authorized entities requesting information

6
Maintenance of Medical Records

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Maintaining the medical records for the patients includes ensuring the accuracy and accessibility of the records for continuity of care throughout the lifetime of the patient. These include both paper and electronic medical records.

7
Filing

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Medical records filing include designing and developing the structure of the health information management system that is 

  • easily accessible
  • organized
  • protects patient confidentiality
  • compliant to the laws and guidelines of HIPAA

8
Privacy and Security

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With the increased use of information technology in health care, your medical office must continue to find ways to maintain the privacy and security of the protected health information (PHI) of the patients they serve.

  • Storage of protected health information in a manner that protects the confidentiality of the patients
  • Implement features that ensure the medical office staff has proper training and authorization to access PHI
  • Utilize encryption controls to protect transmitted data over a network

9
Release of Information

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Patient information may be requested for numerous reasons such as insurance purposes or continuity of care. The medical office has the responsibility to release information in a timely manner upon proper authorization of the patient or their authorized representative. Release of information services include:

  • Obtaining valid authorization for release of protected health information
  • Completion of the medical record for copying
  • Transmitting of the electronic health record
  • Tracking requests and monitoring the timeliness of the response

10
Maintaining Confidentiality

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All healthcare providers have a responsibility to keep their staff trained and informed regarding patient confidentiality. Informing employees protecting patient information should include

  • Proper disposal 
  • Proper storage
  • Proper access
  • Proper disclosure

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