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Based on extensive experience in the field, this book will introduce readers to the principles and practices of Health Information Management through understanding of Health Information Technology and its application today. Topics covered in the book are based on the core competencies defined by AHIMA as well as HIPAA regulations and JACHO recommendations. To prepare for twenty-first century healthcare occupations, the reader needs to understand the connectivity and applications that make up Health Information Systems of today. The book will provide readers with a thorough understanding of both the terminology of Health Information Technology and the practical use of Information Systems in actual medical facilities. Ample illustrations make it easy to visualize workflow scenarios and technical concepts. Photographs of healthcare providers using various HIT systems and medical devices make it easy to see the practical applicability in a medical office.
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Product Details

  • ISBN-13: 9780131592674
  • Publisher: Prentice Hall
  • Publication date: 1/18/2010
  • Series: MyHealthProfessionsKit Series
  • Edition description: New Edition
  • Edition number: 1
  • Pages: 352
  • Sales rank: 280,913
  • Product dimensions: 8.50 (w) x 10.80 (h) x 0.60 (d)

Meet the Author

About the Author

Richard Gartee is the author of four college textbooks on health information technology, computerized medical systems, managed care, and electronic health records. Prior to becoming a full time author and consultant, Richard spent 20 years in the design, development and implementation of leading medical practice and electronic health records systems.

Richard served as Vice-President of Product Development and subsequently as Director of Design Strategy at Medical Manager Research & Development, Inc. He also served as a liaison to other companies in the medical computer industry as well as Blue Cross/Blue Shield, a U.S. Department of Commerce International Trade Mission and various universities.

Richard is a current or past member of many of the professional organizations and national standards groups recommended in this book:

w American Health Information Management Association (AHIMA)

w Healthcare Information Management Systems Society (HIMSS)

w American National Standards Institute (ANSI) X-12n committee for development of electronic claims standards

w Health Level Seven (HL7) committee for development of claims attachment standards

w Workgroup for Electronic Data Interchange (WEDI) taskforce for development of electronic remittance guidelines

w A faculty member/speaker at the Medical Records Institute international Electronic Health Records conference (TEPR) for twelve years.

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Table of Contents

Table of Contents Preface


Learning Made Easy (walk through)

Organization of The Text

A Few Words of Advice

About The Author


Chapter 1 Health Care Delivery Fundamentals

Healthcare Settings

Ambulatory Care Facilities

Acute Care Facilities

Long Term Care Facilities

Rehab Facilities

Home Care

Comparison of Inpatient versus Outpatient

Admission and Discharge

Health Care Providers and Professions

Direct Care Providers



Licensed Practical Nurse

Registered Nurse

Physician Assistant

Allied Health Care Professions

Clinical Allied Health Professions

Non-Clinical Allied Health Professions

Chapter One Summary

Testing Your Knowledge of Chapter 1

Chapter 2 Health Information Professionals

History of Health Information Management

HIT and HIM professions

List of job descriptions and organizational structures

HIM manager or director

Registered Health Information Administrator

Clinical Data Specialist

DRG Coordinator

APC Coordinator

Clinical Coding Specialist

Coding Associate

Medical Transcriber

Cancer Registrar

HIM compliance specialist

Optical Imaging Coordinator

Registered Health Information Technicians

Real Life Story: Building An All Digital Hospital

Clinical Project Manager, IT Project Manager

Clinical Analyst

Clinical Vocabulary Manager

Clinical Applications Coordinator

Data Quality Manager

Data Resource Administrator

Decision Support Analyst

Health Information Systems Department Technician

Enterprise Application Specialist

Integration Architect

Health Systems Specialist

Solution Analyst

Solution Consultant

Systems Analyst

Information Security Manager

Records and Information Coordinator

Officers and Other Positions

Compliance Officer

Privacy Officer

Information Privacy Coordinator

Security Officer

Risk Management Specialist

Utilization Manager

Quality Improvement Director

Senior Document Coordinator

Health Services Manager

Patient Information Coordinator

Clinical Research Associate

Medical Office Manager

Health Insurance Specialist

Real Life Story: Examples of Project Management

Organizations of Importance to HIM or HIT Professionals











Skills For Success

Chapter Two Summary

Testing Your Knowledge of Chapter 2

Chapter 3 Accreditation, Regulation and HIPAA

Accreditation and Regulation


State and Local Laws

The Joint Commission (JCAHO)




Administrative Subsection

HIPAA Transactions and Code Sets

HIPAA Uniform Identifiers

Privacy and Security of Patient Records

HIPAA Privacy Rule

Privacy Policy


Modifying HIPAA Consent



Research Exceptions


Government Agencies

Minimum Necessary

Incidental Disclosures

A Patient’s Right to Know About Disclosures

Patient Access to Medical Records

Health Information Management Responsibilities

Personal Representatives

Minor Children

Business Associates

Civil and Criminal Penalties

Real Life Story: The First HIPAA Privacy Case

HIPAA Security Rule

The Privacy Rule and Security Rule Compared

Security Standards

Implementation Specifications

Administrative Safeguards

Security Management Process

Assign Security Responsibility

Workforce Security

Information Access Management

Security Awareness and Training

Security Incident Procedures

Contingency Plan

Real Life Story: Contingency Plans Ensure Continued Ability to Deliver Care


Business Associate Contracts and Other Arrangements

Physical Safeguards

Facility Access Controls

Workstation Use

Workstation Security

Device and Media Controls

Technical Safeguards

Access Control

Audit Controls


Person or Entity Authorization

Transmission Security

Organizational, Policies and Procedures Documentation Requirements

Organizational Requirements

Policies and Procedures


Chapter Three Summary

Testing Your Knowledge of Chapter 3

Chapter 4 Fundamentals of Computer Systems

The Technology Behind Health Systems



Memory and Storage

Random Access Memory

Hard Drives

Optical Disks

Read Only Memory

Magnetic Tape

Input and Output Devices



Operating Systems

Application Software

Bits and Bytes How a Computer Works

Extending Functionality





Files and Tables

Data Dictionary

Relational Data


Image Storage: File or BLOB


Network Hardware

Clients and Servers

Local Area Networks

Wide Area Networks


Protocols (TCP/IP)

Secure Remote Access

Wireless Networks

Printers and Reports

Report Server


Interoperability standards

Data Elements

Data Sets


Maintaining Interoperability


Communication Systems

E-Mail systems


Real Life Story: A Look Behind The Hospital Network

Chapter Four Summary

Testing Your Knowledge of Chapter 4

Chapter 5 Health Care Records

Understanding Health Care Records

Functions of Health Care Records

Primary and Secondary Uses of Records

Types and Structure of Health Records

Transition From Paper To Electronic Records

Health Record contents

Administrative and Demographic Data

Consent and Directives

HIPAA Consent to Use and Disclose PHI

Consent to Treatment

Informed Consent

Refusal of Treatment

Medicare Patient Rights Statement

Assignment of Benefits

Advance Directives

Organ Donor

Personal Property List

Disclosure Records

Clinical Documents

Medical History

Physical Exam

Diagnostic and Therapeutic Orders

Diagnostic and Therapeutic Reports

Diagnostic Images

Operative Records

Nursing Notes

Referral Consults

Case Management

Discharge Summary

Obstetrical Records

Pediatric Records

Public Health Records

Continuity of Care Record


Who Owns The Record?

The Personal Health Record



Reporting Home Nursing Visits

Patient Reporting And Telemonitors


Chapter Five Summary

Testing Your Knowledge of Chapter 5

Chapter 6 Organization, Storage and Management of Health Records

How Paper Charts Are Organized

Source Oriented Record

Problem Oriented Record

Integrated Record

Electronic Views

Filing Paper Records

Paper Chart Numbering Systems

Paper Chart Filing Systems

Terminal Digits Filing

Color Coding

Record Storage and Circulation

Calculating Storage

Chart Locator Systems

Legal and Ethical Management of Health Records

Record Retention

Real Life Story: You Never Know What You Don’t Know

Destruction of Health Records

Release of Information

HIM and HIT Ethics

AHIMA Code of Ethics

Chapter Six Summary

Testing Your Knowledge of Chapter 6

Chapter 7 Electronic Health Records

Electronic Medical Records




EHR Defined

Social Forces Driving Adoption

Health Safety

Health Costs

Government Response

Functional Benefits of an EHR

Health Maintenance

Trend Analysis


Decision Support


Medical References


Form Affects Functionality

Standard EHR Coding Systems




Advantages of Codified Records

Health Maintenance

Trend Analysis


Decision Support

Documenting At The Point of Care

Benefits of Real Time Documentation

Document storage and image retrieval systems

Quality Control

Real Life Story: Where’s My Chart?

Flow of An Office Fully Using EHR

Electronic Signatures

How Digital Signatures Work

Methods of Capturing and Recording Data

Clinician Entered Data

Saving Clinicians Time






Flow Sheets



Patient Entered Data

Workflow Using Patient Entered Data

Preventive Health Screening

Alternative Workflow


Workflow of An E-Visit

Health Maintenance


Preventative Care Screening

Using EHR Data For Alerts

Reactions to Drugs or Other Treatments

Other Types Of Alerts

Decision Support

Chapter Seven Summary

Testing Your Knowledge of Chapter 7

Chapter 8 Additional Health Information Systems

Departmental Systems

LIS and device systems

Radiology department

Cat, CT, PET, MRI etc.

Digital images

Voice recognition

Pharmacy systems

Dispensing Systems

Drug Trials

ER systems

Scheduling Systems




Implant Records

Chapter Eight Summary

Testing Your Knowledge of Chapter 8

Chapter 9 Health Care Business Systems

Administration and Business Systems


Master Patient Indexes

Insurance Eligibility

Episode vs. continuing care


Coding, Billing and Reimbursement

Batch and Real-time posting

Transaction Standards

Electronic Claims

Paper Claims


CMS 1500

Electronic Remittance

Prospective Payment System


Accounting and Tax Records


Purchasing and Supplies

Inventory Control

Chapter Nine Summary

Testing Your Knowledge of Chapter 9

Chapter 10 Health Statistics, Research and Quality Improvement

Secondary Health Records

Using Data Analysis and Research

Health Care Statistics

Using codified data

Coding and abstracting reports






Text analysis processing

Chapter Ten Summary

Testing Your Knowledge of Chapter 10

Chapter 11 Information Systems for Managerial Support

Administrative Records

Maintenance Records

Personnel Records




Continuing Education Unit records

Incident Records

Chapter Eleven Summary

Testing Your Knowledge of Chapter 11

Chapter 12 Principles of Management

Workflow and Design

Project Management

Change Management

Training and Education Systems

Upgrades and Test environments

Chapter Twelve Summary

Testing Your Knowledge of Chapter 12

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