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Ten Responsibilities of Health Information Management

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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 ten responsibilites within the framework of health information management.

1. Medical Coding

Medical coding includes the correct assignment of medical codes for maximum reimbursement.  It also means insuring that all health records are properly diagnosed according to the ordered procedure.

2. Medical Transcription

Medical transcription refers to the accurate and timely transcription of 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

3. Medical Necessity

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

A large portion of health information management is providing informations to physicians on those patients being treated by them as requested and reviewing the records for compliance with state, federal and private insurance guidelines.

5. Assembly of Medical Records

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

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.

7. Filing

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

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

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:

10. Maintaining Confidentiality

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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