Health Information Management

OUT OF PRINT - NO LONGER AVAILABLE

If you'd like this text updated please contact AHIMA directly. It is not the decision of Physicians' Record Company to have this text discontinued. We would also like to have an updated version of the "Medical Record Bible" available to all of today's health information professionals. However, it is AHIMA's choice not to update the text that has educated so many, for so long. They can be reached via phone at (312) 233-1100 or via email at info@ahima.org.

This reference provides the recognized and accepted standard for health information science. Recognized as the core resource for educators, students, and practicing professionals, this classic text outlines the basic concepts of the field.

As with previous editions, the tenth revision of Medical Record Management, now known as Health Information Management, is intended to be a basic textbook and reference for the field of medical records and health information management. Edna K. Huffman, the original author of this text, was one of the first educators in the field of medical record management and the seventh president of the American Health Information Management Association (then known as the American Association of Medical Record Librarians). Her dedication to the advancement of the profession through education has been the impetus for the Association to continue revising her book over the years. This revision provides general information on a broad range of topics.

Key changes in the 1994 revision include updated references to JCAHO standards and accreditation: current information on computer applications in health information services, including an emphasis on computerization of indexes and registers: enhanced content on quality improvement and applications in health information management departments: and information on new federal laws and their impact on health information departments.

"An Excellent Source for Health Information Professionals" March 24, 2001

Reviewer: Julie K. from Plainview, NY United States
"Health Information Management is a great resource for health information professionals. Every RHIA or RHIT must acquire this book. We can refer to it daily as it succinctly describes our work. Any questions we have - this book can answer. Even though it was published in 1994, the majority of the information is still relevant. The book is an excellent historical source for medical records. The book is written in a simple form that is highly understandable to laypeople. I recommend it to anyone entering the field of health information. The book will be your bible for years to come."

 

Good start, July 31, 2004

Reviewer: J. P Panas "Health Guy"

"I liked this book. It was a good beginner on health information management."

CHAPTER BY CHAPTER INDEX

CHAPTER 1

INTRODUCTION TO HEALTH INFORMATION MANAGEMENT

• Health Information Management
• Evolution of Health Care in the United States
• Health Care Today
• Health Care Practitioners
• Health-Related Associations, Organizations and Agencies
• The Health Care Consumer
• The Medical Record
• The American Health Information Management Association
• Code of Ethics
• The Health Information Management Professional
• International Federation of Health Record Organizations
• Summary
• Study Questions
• References

CHAPTER 2

DEVELOPMENT AND CONTENT OF THE HOSPITAL MEDICAL RECORD

• Content of the Medical Record
• Special Records
• Format Types
• Required Characteristics of Entries in Medical Records
• Summary
• Study Questions
• References

CHAPTER 3

MEDICAL RECORDS IN AMBULATORY CARE

• Factors Influencing Use of Ambulatory Care
• Ambulatory Care
• Ambulatory Care Records
• Medical Records in Free-Standing Facilities
• Analysis of Ambulatory Care Records
• Quality Management
• Summary
• Study Questions
• References

CHAPTER 4

CLINICAL RECORDS IN LONG TERM CARE AND REHABILITATION FACILITIES

• Long Term Care Facilities
• Nursing Facilities
• Home Care
• The Hospice
• Respite Care
• Rehabilitation Facilities
• General Medical Record Management Principles
• Retention of Records
• Release of Information
• Consulting
• Summary
• Study Questions
• References

CHAPTER 5

MENTAL HEALTH RECORD

• History of Mental Health Care in the United States
• Content of Mental Health Records
• Patient Management
• Special Therapies
• Record Documentation
• Review Process
• Utilization Review
• Release of Information
• Summary
• Study Questions
• References

CHAPTER 6

MANAGEMENT OF MEDICAL RECORD CONTENT

• Types of Medical Record Documentation Analyses
• Handling Information on Documentation Practices and Potentially Compensable Events
• Summary
• Study Questions
• References

CHAPTER 7

FORMS DESIGN AND CONTROL

• Forms Design
• Forms Control
• Summary
• Study Questions
• References

CHAPTER 8

FILING METHODS, STORAGE AND RETENTION

• Record Numbering and Filing Systems
• Physical Facilities in the File Area
• Protective Covers for Records
• Safety
• Organizational Patterns of Files
• Record Control
• Locating Misfiles
• Color Coding of Record Folders
• Other Filing Rules and Procedures
• Transportation of Records
• Medical Record Retention Policies
• Microfilming
• Disk Storage
• Summary
• Study Questions
• References

CHAPTER 9

NOMENCLATURES AND CLASSIFICATION SYSTEMS

• Nomenclatures and Classification
• Nomenclatures
• Statistical Classifications
• Other Classifications
• Choosing a Classification System
• Encoding Systems
• Summary
• Study Questions
• References

CHAPTER 10

INDEXES AND REGISTERS

• Master Patient Register
• The Number Index
• Disease and Procedure Indexes
• Physicians' Index
• Registers
• Cancer Registry
• Data Quality
• Summary
• Study Questions
• References

CHAPTER 11

HEALTH CARE STATISTICS

• Introduction
• Determination of Collection Needs
• Glossary of Health Care Terms
• Computation of Percentages
• Inpatient Census and Rates Computed From It
• Measures of Central Tendency and Variation
• Presentation of Data
• Ambulatory Care Statistics
• Long Term Care Statistics
• Quality Control of Data Collection Systems
• Vital Records and Statistics
• The Vital Statistics Registration System of the United States
• Definitions for Reporting of Reproductive Health Statistics
• Research Studies Summary
• Study Questions
• References

CHAPTER 12

HEALTH INFORMATION IN REIMBURSEMENT

• The Issue
• History of Reimbursement
• Prospective Payment System
• PPS Impact and Evolving Reimbursement Reform
• Summary
• Study Questions
• References

CHAPTER 13

COMPUTER SYSTEMS IN HEALTH CARE

• Introduction
• Computer Dynamics
• Definition of Terms
• Systems Analysis
• Computer Systems
• Computerized Patient Records
• Summary
• Study Questions
• References

CHAPTER 14

INFORMATION SYSTEMS IN HEALTH CARE

• Introduction
• Financial Applications
• Medical Record Department
• Word Processing
• Clinical Applications
• Ambulatory Care Systems
• Data Accuracy
• Data Security, Privacy and Confidentiality
• Summary
• Study Questions
• References

CHAPTER 15

THE LEGAL ASPECTS OF MEDICAL RECORD INFORMATION

• Sources of Legal Requirements
• Legal Aspects of Medical Records
• Confidentiality of Medical Records
• Laws and Regulations Regarding Medical Records
• Voluntary Release of Information
• The Medical Record in Court
• Ethical Issues
• Secondary Records
• Summary
• Study Questions
• References

CHAPTER 16

THE MANAGEMENT OF QUALITY

• External and Internal Pressures for Quality
• Quality Assessment and Quality Improvement
• Utilization Management
• Peer Review Organization (PRO)
• JCAHO Utilization Review Requirements
• Organization of a Hospital Utilization Management Program
• Utilization Review Process
• Screening Criteria
• Outcomes of Utilization Management
• Credentialing
• Medical Staff Office
• Risk Management Program
• Components of a Risk Management Program
• Elimination or Reduction of Possible Risks
• Organization and Operation of a Risk Management Program
• Summary
• Study Questions
• References

CHAPTER 17

HEALTH INFORMATION DEPARTMENT MANAGEMENT

• Overview of Management
• The Planning Function
• The Organizing Function
• The Directing Function
• The Controlling Function
• Summary
• Study Questions
• References

CHAPTER 18

MANAGEMENT OF HEALTH INFORMATION DEPARTMENT PERSONNEL

• Communication
• Personnel Supervision
• Summary
• Study Questions
• References

LIST OF ILLUSTRATIONS

INDEX

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