Health Information Management (HIM) is a multifaceted department supporting patient care areas as well as administrative departments with 24/7operations. HIM processes public/patient and payer requests concerning medical records.
HIM is organized into units that handle specific functions:
Dictation and Transcription
Forms Management, Research, Quality Reporting, Medical Record Review
Release of Information
SOME KEY POSITIONS IN HIM:
Coder (inpatient and outpatient):
Assigns codes for all primary and secondary diagnoses and procedures while ensuring completeness and quality of record coding.
Rep I and II :
Ensures proper maintenance of patient charts and records, and reviews requests for release of patient information. Reps also retrieve medical records and analyze record content for compliance purposes.
Coordinates work assignments and priorities to meet department requests; responsible for achieving defined accuracy and production targets and performs quality assurance activities.
Health Information Management Record Processing is open 7 days a week to retrieve, assemble and analyze medical records of patients discharged from the hospital or seen in outpatient areas. Records are retrieved daily from all inpatient units and regularly from outpatient areas; assembled in a specific order for ease of information access for continuing patient care; and analyzed for completion requirements in accordance with Joint Commission and hospital bylaws.
Coding is a procedure that assigns numeric code to diagnosis and procedural data on a medical classification system. The coders use the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), which is accepted and used worldwide. The purpose of these codes is to retrieve data about specific diseases, analyze trends of disease, and provide information for billing and review of procedures. Barnes-Jewish Hospital has inpatient and outpatient coders.
DICTATION AND TRANSCRIPTION
The dictation and transcription unit is responsible for tracking and processing dictated reports and distributing transcribed reports.
This area is responsible for assisting physicians and allied health practitioners with their record completion responsibilities. It houses seven workstations with dictation and other amenities that providers can use while completing medical records.
FORMS MANAGEMENT, RESEARCH CHART REQUESTS, QUALITY REPORTING, MEDICAL RECORD REVIEW
This area collects data based on the TJC Information Management Standards-Regulatory Agencies, identifies problems, and recommends actions to resolve the problems identified in patient care areas. Also, this area works with the Barnes-Jewish Hospital Forms Committee to ensure that all forms and documents included in the permanent medical record complies with the hospital's forms standards.
HIM department has three locations at Barnes-Jewish Hospital: two on the North Campus for record processing and 1 satellite office on the south campus for physician documentation support and record requests.
Other HIM employment opportunities include:
Release of Information (ROI)
Clinical Documentation Specialist
Scanning, Phone Desk (Reception)