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Question
Describe the main activities of a Health Information Management (HIM) Department, professionals employed in this department, workforce requirements, eligibility requirements for HIM credentials, professional associations, and the accrediting body for HIM educational programs. Describe the recent trends in healthcare delivery, functions of clinical documentation and health records, and the importance of defining the legal health record. Identify the persons responsible for completing the data, required content, signatures/authentications as well as maintaining the quality of the health record for all documentation routinely found in a health record. Interpret health record content identifying where specific patient demographic and clinical data can be found and what makes a complete health record. Identify the content and purpose of a master patient index (MPI), various types of MPI content errors, and patient matching techniques. Describe formats of paper health records, records processing, filing and retrieval of patient paper records, filing equipment, and chart tracking systems as well as differences between record processing required in paper systems vs. electronic health record systems. Apply policies and procedures to ensure the accuracy and integrity of health data. Identify ways to prevent and detect medical identity theft as well as procedures to follow when medical identity theft occurs.
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