Definition of HIM
HIM is the practice that involves the acquiring, protecting and analyzing traditional and digital medical information essential to giving quality health care to patients. It combines the information technology, science, and business. Hersh & Wright (2008) explains that the professionals in HIM have adequate training in the recent information management technology applications, and they have mastered the scope of operations in any healthcare providing organizations beginning from the large systems in hospitals to the physicians practicing on private. These specialists are crucial to the daily working management of health information and the electronic health record (EHRs). They make sure the clients health information and the records are accurate, protected, and complete.
Review of AHIMAs History, Mission and Future Forecasts
The American Health Information Management Association (AHIMA) is an organization in the healthcare area focusing on management of health records in the most efficient way possible (Ludwick & Doucette, 2009). These are some of the statistical records of medical nature required for smooth delivery of excellent healthcare services to the patients.
Place New Order
The United States of America has a rich history of health information management. The industry can be tracked back to the 1920s. It was the time of understanding the importance of documenting the information related to patient care and the attached benefits both for the patients and healthcare providers. These records contained the details, problems, and even the results of patient care. Thus, keeping this information brought the realization by healthcare providers that patients could get better treatments based on the accurate and complete medical records. Therefore, the practice became famous all over the nation. Later, in the year 1928, the American College of Surgeons (ACOS) had a sole focus on advancing the standards of the records generating from the clinical settings (Ludwick & Doucette, 2009). The standardization of these clinical data was introduced through developing the American Association of Record Librarians, an association of professionals that currently exits under the name American Health Information Management Association (AHIMA).
The mission of AHIMA was to be a community of experts focused on improving the healthcare through advancing excellent standards and practices for the health information management and being a reliable source of research, credentialing of professionals, and education. AHIMA is the leading force in community information management and developing professional standards and practice. It works on promoting some of these missions by; informatics (where data will be transformed into healthcare intelligence), innovation (advancing new approaches to leadership), and HIM research based on evidence (Hersh & Wright, 2008). It also aims at raising the leaders and managers for the healthcare divisions that would ensure proper governance of information that leads to their recognition as industry experts. Finally, it benefits the real public by empowering he patients by the management of individual health information.
Currently, the health information administration in this industry is focuses on its functioning under the primary objective of the first medical record librarians; improving and increasing the documentation of clinical records standards. Ludwick & Doucette (2009) states that the industry has moved a long way from keeping the health records in copies, but the ultimate objective of an entirely functional HER has yet to be introduced.
Increased changes are seen in the health information management industry even as they are trying to advance sufficiently to the practical HER system. The most essential of all aspects to be considered to ensure excellent performance of the system is not just data but the capability to get critical awareness from the data. The organizations that are traditional will finally understand well the vital issues of not only collecting the data but doing it responsibly and quickly, analyzing it, and delivering the said data to the professionals who need it mostly for advice (Ludwick & Doucette, 2009).
Discuss Documentation Guidelines Developed by AHIMA
Policies and Procedures
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According to its guidelines, CDI departments have to ensure good management, but written policies and procedures and the development of these systems have to get assistance from other ministries that are affected by the documentation rules. These guideleines include education, the experience and the credentials of hiring CDI professionals; initial training and orientation; ongoing education and training; compliant query practices; and a CDI quality assurance process (Hersh & Wright, 2008). These aspects will be essential in the case of the 30-year-old individual tested for HIV since a healthcare provider will have to determine a specialsit that will be handling the patient the next time. Moreover, there will be no need to run the test again due to the availabiliyu of detailed and informative documentation on the history of the patients health including the HIV test results. With all these credentials of hiring and education based on the departmental level, the information about this patient will be completely documented giving a possibility to offer the quality health care to the patient in the future without the need to undergo the routine tests.
Roles, Competence, and Staffing Models
In documenting the clinical encounters, HIM providers are expected to offer legible, complete, clear, precise, consistent, and reliable documentation of a patients health history, the illness at present and the cause of the treatment. The documentation thus includes observations, the evidence of medical decision-making in determining a diagnosis, treatment plan, and the results of all tests, procedures, and treatment (Ludwick & Doucette, 2009). The clinical documentation has to be complete and exact to the maximum possible level, as well as include information on the severity, specificity of anatomic sites involved, and etiology of symptoms. Thus, having been discharged after being given intravenous fluids and just antibiotics, there has to be enough of well-documented health records about the health condition of the patient even after the diagnosis of HIV/AIDS. Due to the availability of this data and the existing clear records health professional can easily administer treatment to him and reliese = home. The test results of that time definably will be documented again as per these guidelines of legible, complete, clear, precise, consistent, and reliable documentation of a patients health history, the illness present time HIV/AIDS, and the cause of the treatment
Describing How Recent and Future Technological Changes in Health Records Management has/will Impact the Chosen Career Path as a Health Professional
The essential aspects of HIM profession continue to evolve over time and become less based on paper media thus increasing itself electronically. Some of these factors influencing the environment of health care have the direct impact on the HIM profession. Currently, the professionals in HIM are not placed in one single centralized department but are mostly decentralized, which enables them to apply their expertise across the whole organization (Hersh & Wright, 2008). Also, the academic and the continued educational programs in HIM are dynamic. They are developing, growing and aligning themselves with the latest challenges in the industry. As a result of raising demands in the healthcare industry, HIM adopts important strategies to enable the growth of professionals and improve its role in health care delivery. These strategies include the development of professionals laying a higher focus on their specialization in the areas of technical expertise and boosting the number of certificates that are advanced. Another strategy involves the promotions and enhancing of programs in education to raise the number of qualified professionals in HIM. Thus, the possibility to have a career development will definitely boost the motivation of the professionals to improve, as well as it will stimulate young individuals to choose a career in the health profession, particularly HIM.
The HIM field is amidst the process often referred to as creative destruction where the existing technologies are destroyed, and new technology come into play. Thus, the role of HIM professional becomes significant since paper-form records converse to electronic health records (EHRs). This shift already impacts the industry as the major old functions of HIM professionals that mostly surrounded the paper medical records get eliminated and are replaced by the new roles related to electronic health records handling (Ludwick & Doucette, 2009). The role of HIM professionals has become integral for the transfer and transition of patients information regarding the implementation of EHRs. The rapid growth in HIM and the expanding role of HIM professionals have already had and will have a massive impact on careers of those health professionals in it.