Health records management classification Health Informatics HI is

Health records management classification

§Health Informatics (HI) is a science that defines how health information is technically captured, transmitted and utilized. §Health informatics focuses on information systems, informatics principles, and information technology as it is applied to the continuum of healthcare delivery.

§Health Informatics (HI) is a science that defines how health information is technically captured, transmitted and utilized. §Health informatics focuses on information systems, informatics principles, and information technology as it is applied to the continuum of healthcare delivery.

§It is an integrated discipline with specialty domains that include management science, management engineering principles, healthcare delivery and public health, patient safety, information science and computer technology. §Health Informatics programs demonstrate uniqueness by offering varied options for practice or research focus.

§There are four major focus research areas in informatics education reflecting various disciplines: § Medical/Bio Informatics – physician and research based, attracts medical students § Nursing Informatics – clinical and research based, attracts nursing students § Public Health Informatics – public health and biosurveillance based, attracts public health students § Applied Informatics – addresses the flow of medical information in an electronic environment and covers process, policy and technological solutions, attracts HIM students

§The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction. §The medical record includes a variety of types of "notes" entered over time by health care professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc.

§The terms are used for both the physical folder that exists for each individual patient and for the body of information found therein. §Medical records have traditionally been compiled and maintained by health care providers, but advances in online data storage have led to the development of personal health records (PHR) that are maintained by patients themselves, often on third-party websites.

§Because many consider the information in medical records to be sensitive personal information covered by expectations of privacy, many ethical and legal issues are implicated in their maintenance, such as third-party access and appropriate storage and disposal. §Although the storage equipment for medical records generally is the property of the health care provider, the actual record is considered in most jurisdictions to be the property of the patient, who may obtain copies upon request.

Purpose �The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. � The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. �An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.

Contents �Medical history �Surgical history �Medications and medical allergies �Family history �Social history �Habits �Growth chart and developmental history �Assessment and plan �Orders and prescriptions �Progress notes �Test results…. . Etc. .

Contents �Ownership of patient's record �Accessibility �Destruction �In general, entities in possession of medical records are required to maintain those records for a given period. �In the United Kingdom, medical records are required for the lifetime of a patient and legally for as long as that complaint action can be brought.

Contents �Generally in the UK, any recorded information should be kept legally for 7 years, but for medical records additional time must be allowed for any child to reach the age of responsibility (20 years). � �Medical records are required many years after a patient’s death to investigate illnesses within a community (e. g. , industrial or environmental disease or even deaths at the hands of doctors committing murders, as in the Harold Shipman case).

Abuses, Breaches & Privacy �The outsourcing of medical record transcription and storage has the potential to violate patient-physician confidentiality by possibly allowing unaccountable persons access to patient data. �Falsification of a medical record by a medical professional is a felony in most United States jurisdictions. �Governments have often refused to disclose medical records of military personnel who have been used as experimental subjects.

Data Breach �Given the series of medical data breaches and the lack of public trust, some countries have enacted laws requiring safeguards to be put in place to protect the security and confidentiality of medical information as it is shared electronically and to give patients some important rights to monitor their medical records and receive notification for loss and unauthorized acquisition of health information. �The United States and the EU have imposed mandatory medical data breach notifications.

Privacy �The federal Health Insurance Portability and Accessibility Act (HIPAA) addresses the issue of privacy by providing medical information handling guidelines. (US)

Classification of Healthcare Records �Medical classification, or �medical coding, �is the process of transforming descriptions of medical diagnoses and procedures into universal medical code numbers.

medical procedure s medical diagnoses universal medical code numbers

Classification of Healthcare Records �Medical classification, or medical coding, is the process of transforming descriptions of medical diagnoses and procedures into universal medical code numbers. �The diagnoses and procedures are usually taken from a variety of sources within the health care record, such as the transcription of the physician's notes, laboratory results, radiologic results, and other sources.

Medical classification systems are used for a variety of applications in medicine, public health and medical informatics, including: qstatistical analysis of diseases and therapeutic actions qreimbursement; e. g. , based on diagnosisrelated groups qknowledge-based and decision support systems qdirect surveillance of epidemic or pandemic outbreaks There are country specific standards and international classification systems.

Classification Types of coding systems specific to health care include: Diagnostic codes Are used to determine diseases, disorders, and symptoms Can be used to measure morbidity and mortality Examples: ICD-9 -CM, ICD-10 Procedural codes They are numbers or alphanumeric codes used to identify specific health interventions taken by medical professionals. Examples: ICPM, ICHI Pharmaceutical codes Are used to identify medications Examples: AT, NDC Topographical codes Are codes that indicate a specific location in the body Examples : ICD-O, SNOMED

SNOMED q. The Systematized Nomenclature of Medicine (SNOMED) is the most widely recognised nomenclature in healthcare. q. Its current version, SNOMED Clinical Terms (SNOMED CT), is intended to provide a set of concepts and relationships that offers a common reference point for comparison and aggregation of data about the health care process. q. SNOMED CT is often described as a reference terminology.

SNOMED v. SNOMED CT contains more than 311, 000 active concepts with unique meanings and formal logic-based definitions organised into hierarchies. v. SNOMED CT can be used by anyone with an Affiliate License, 40 low income countries defined by the World Bank or qualifying research, humanitarian and charitable projects. v. SNOMED-CT is designed to be managed by computer, and it is a complex relationship concepts.

SNOMED v. SNOMED CT and ICD are designed for different purposes and each should be used for the purposes for which they were designed. v. As a core terminology for the EHR, SNOMED CT provides a common language that enables a consistent way of capturing, sharing, and aggregating health data across specialties and sites of care.

SNOMED v. SNOMED CT is used directly by healthcare providers during the process of care, whereas ICD is used by coding professionals after the episode of care.

SNOMED CT

SNOMED CT v. SNOMED Clinical Terms is a systematically organized computer processable collection of medical terms providing codes, terms, synonyms and definitions used in clinical documentation and reporting. v. SNOMED CT (Systematized Nomenclature of Medicine -- Clinical Terms) is a standardized, multilingual vocabulary of clinical terminology that is used by physicians and other health care providers for the electronic exchange of clinical health information.

SNOMED CT v. SNOMED CT is considered to be the most comprehensive, multilingual clinical healthcare terminology in the world. v. SNOMED CT provides the core general terminology for electronic health records. SNOMED CT comprehensive coverage includes: clinical findings, symptoms, diagnoses, procedures, body structures, organisms and other etiologies, substances, pharmaceuticals, devices and specimen.

SNOMED CT v. SNOMED CT provides for consistent information interchange and is fundamental to an interoperable electronic health record. v. It allows a consistent way to index, store, retrieve, and aggregate clinical data across specialties and sites of care. v. It also helps in organizing the content of electronic health records systems by reducing the variability in the way data is captured, encoded and used for clinical care of patients and research.

SNOMED CT v. SNOMED CT can be used to record clinical details of individuals in the electronic patient records. v. It also provides the user with a number of linkages to clinical care pathways, shared care plans and other knowledge resources, in order to facilitate informed decision-making and support long term patient care. v. The availability of free automatic coding tools and services, which can return a ranked list of SNOMED CT descriptors to encode any clinical report, could help healthcare professionals to navigate the terminology.

SNOMED CT v. SNOMED CT is a terminology that can cross-map to other international standards and classifications. v. SNOMED CT is a multinational and multilingual terminology, which can manage different languages and dialects. v. SNOMED CT is currently available in American English, British English, Spanish, Danish and Swedish, with other translations under way or nearly completed in French and Dutch.