As A Health Information Management (HIM) Professional It Is

As A Health Information Management Him Professional It Is Critical T

As a Health Information Management (HIM) professional, it is critical to have a strong understanding of your responsibilities regarding health records. For this assignment, complete the following steps. List the nine clinical and nonclinical uses of the health record. Explain why it is important to know the different uses of the health record. Identify the HIM professional's responsibilities as custodian of the health record. Demonstrate your knowledge of the following by writing definitions in your own words for the following terms. Your definitions should be 2-3 sentences per term. Subpoena Subpoena ad testificandum Subpoena duces tecum.

Paper For Above instruction

Introduction

The health record is an essential component of healthcare delivery and management, serving multiple purposes that encompass clinical, administrative, legal, and educational functions. As a Health Information Management (HIM) professional, understanding these diverse uses and responsibilities is vital to ensure the integrity, confidentiality, and proper utilization of health records. This paper explores the nine clinical and nonclinical uses of health records, discusses the importance of recognizing these functions, and examines the core responsibilities of HIM professionals as custodians of health information. Additionally, definitions of key legal terms related to health records are provided to deepen understanding of legal procedures surrounding health information.

Nine Clinical and Nonclinical Uses of the Health Record

The health record serves numerous purposes, divided into clinical and nonclinical categories. The nine uses include:

  1. Patient Care and Treatment
  2. Continuity of Care
  3. Legal Documentation
  4. Billing and Reimbursement
  5. Quality Improvement and Data Analysis
  6. Research and Education
  7. Regulatory Compliance
  8. Public Health Tracking
  9. Medical Coding and Documentation

Each of these uses highlights the vital role of accurate and comprehensive health records in ensuring effective healthcare delivery and administration.

Importance of Knowing the Different Uses of the Health Record

Understanding the various uses of health records is crucial for HIM professionals because it underpins the integrity and confidentiality of patient information. Recognizing how health records are employed in clinical decision-making, legal proceedings, billing, and research enables HIM professionals to manage records responsibly, ensure compliance with laws and regulations, and support overall healthcare quality. Moreover, this knowledge assists in safeguarding patient privacy while facilitating the appropriate sharing and use of health information across different settings. Being aware of these applications also aids in maintaining the accuracy and completeness of records, which directly impacts patient safety, billing accuracy, and healthcare outcomes.

HIM Professional's Responsibilities as Custodian of the Health Record

As custodians of health records, HIM professionals bear the responsibility of maintaining the confidentiality, integrity, and accessibility of patient information. They ensure that health records are accurate, complete, and stored securely, adhering to legal and ethical standards. HIM professionals are also tasked with controlling access to health information, providing authorization for record disclosures, and facilitating record retrieval for clinical or legal purposes. Additionally, they are responsible for implementing policies related to record retention and destruction, ensuring compliance with applicable laws such as HIPAA, and supporting data quality initiatives that enhance patient care and operational efficiency. Overall, their role is integral to protecting patient rights and supporting organizational compliance.

Legal Terms Related to Health Records

Subpoena

A subpoena is a legal document issued by a court or legal authority that commands an individual or organization to provide evidence or testify in a legal proceeding. In the context of health records, a subpoena requires a healthcare provider or HIM professional to produce specific patient records or testify regarding certain information relevant to a case, under penalty of legal sanctions if ignored.

Subpoena ad testificandum

A subpoena ad testificandum is a type of subpoena that specifically orders a person to appear and give testimony in a legal proceeding. It does not necessarily require the production of documents but compels personal appearance for the purpose of providing sworn testimony related to the case.

Subpoena duces tecum

A subpoena duces tecum is a legal order directing a person or organization to produce documents, records, or evidence for inspection or copying in a legal matter. When relating to health records, this subpoena compels healthcare facilities or HIM professionals to produce specified patient records for review by the court or involved parties.

Conclusion

The health record is a multifaceted asset serving clinical, administrative, legal, and research purposes. HIM professionals play a vital role as custodians, ensuring the proper management, confidentiality, and legal compliance of health information. Understanding the various uses of health records and related legal terminology enhances their ability to uphold ethical standards and support quality healthcare delivery. As healthcare continues to evolve with technology and legal standards, the responsibilities of HIM professionals remain fundamental to safeguarding patient rights and ensuring the effective use of health information.

References

  1. American Health Information Management Association. (2020). AHIMA Practice Brief: Managing Confidentiality of Health Data. Journal of AHIMA, 91(3), 28-35.
  2. HealthIT.gov. (2021). Understanding the Importance of Health Records. U.S. Department of Health & Human Services.
  3. Rothrock, J. R., & Miller, R. D. (2019). Legal Aspects of Health Records. In Fundamentals of Health Information Management (4th ed., pp. 165-186). Elsevier.
  4. U.S. Department of Justice. (2022). Subpoenas, Legal Holds, and Record Preservation. Justice Department Resources.
  5. Hersh, W. R., et al. (2018). Medical informatics: Improving health care through information. Springer.
  6. Rothman, M. & Kesselheim, A. (2021). Legal issues and health records. Journal of Law, Medicine & Ethics, 49(2), 218-224.
  7. Capriotti, J. M. (2020). The role of health information management professionals in compliance and security. Journal of Healthcare Management, 65(4), 265-276.
  8. World Health Organization. (2019). WHO guidelines on the collection of health data for public health purposes.
  9. HHS.gov. (2020). HIPAA Privacy and Security Rules. U.S. Department of Health & Human Services.
  10. McWay, D. C. (2018). Legal aspects of health records management. Health Law Journal, 53(2), 73-90.

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