Essentials of Health Information Management :

A comprehensive resource for the academic and professional learner, this book presents both theoretical and practical applications throughout. The authors' dynamic and unique approach to health information management targets students who respond to hands-on and visual learning. The book has been written for the first-semester learner; however it can be a useful resource for various health care organizations and medical offices.

Preface

ix

Health Care Delivery Systems

1

(34)

History of Medicine and Health Care Delivery

3

(9)

Continuum of Care

12

(1)

Health Care Facility Ownership

13

(1)

Health Care Facility Organizational Structure

14

(15)

Licensure, Regulation, and Accreditation

29

(6)

Health Information Management Professionals

35

(20)

Careers

36

(8)

Professional Practice Experience

44

(5)

Join Your Professional Association

49

(6)

Health Care Settings

55

(18)

Acute Care Facilities (Hospitals)

57

(2)

Ambulatory and Outpatient Care

59

(3)

Behavioral Health Care Facilities

62

(1)

Home Care and Hospice

62

(1)

Long-Term Care

63

(1)

Managed Care

64

(2)

Federal, State, and Local Health Care

66

(7)

The Patient Record: Hospital, Physician Office, and Alternate Care Settings

73

(36)

Definition and Purpose of the Patient Record

75

(5)

Provider Documentation Responsibilities

80

(6)

Development of the Patient Record

86

(2)

Patient Record Formats

88

(7)

Archived Records

95

(6)

Patient Record Completion Responsibilities

101

(8)

Content of the Patient Record: Inpatient, Outpatient, and Physician Office

109

(84)

General Documentation Issues

111

(3)

Hospital Inpatient Record---Administrative Data

114

(16)

Hospital Inpatient Record---Clinical Data

130

(47)

Hospital Outpatient Record

177

(2)

Physician Office Record

179

(1)

Forms Control and Design

180

(13)

Numbering & Filing Systems and Record Storage & Circulation

193

(32)

Numbering Systems

194

(4)

Filing Systems

198

(7)

Filing Equipment

205

(3)

File Folders

208

(5)

Filing Controls

213

(4)

Loose Filing

217

(1)

Circulation Systems

217

(2)

Security of Health Information

219

(6)

Indexes, Registers, and Health Data Collection

225

(28)

Indexes

227

(7)

Registers and Registries

234

(6)

Case Abstracting

240

(5)

Health Data Collection

245

(8)

Legal Aspects of Health Information Management

253

(40)

Legal and Regulatory Terms

255

(5)

Maintaining the Patient Record in the Normal Course of Business

260

(1)

Confidentiality of Information and HIPAA Privacy and Security Provisions

261

(10)

Legislation that Impacts Health Information Management

271

(5)

Release of Protected Health Information

276

(17)

Coding and Reimbursement

293

(32)

Nomenclatures and Classification Systems

294

(6)

Third-Party Payers

300

(2)

Health Care Reimbursement Systems

302

(23)

Appendix I

325

(6)

Internet Links

331

(10)

Glossary

341

(24)

Bibliography

365

(4)

Index

369

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Essentials of Health Information Management : Principles and Practices

Summary

Table of Contents

Supplemental Materials