Purpose and Function of the Health Record

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Carol Alborn HIM CORE Day 11 9/12/2011 Purpose and Function of the Health Record A health record is a virtual storage place that documents health care services from healthcare providers at various locations such as the DR.’s office, nursing homes and ambulatory service locations. It’s made up of data or facts from the patient and family members, and these healthcare services, which is analyzed for useful information. It is the HIM professional’s responsibility to take data from traditional practice forms and any Personal Health Record (PHR) or from any other sources, then enter data into the Electronic Health Record (EHR) system. Anything missing can alter the patients care. Its Primary purpose is to ensure quality patient care and managing the cost of that care. Its secondary purpose as defined by the Institute of Medicine (IOM) deals with individual users for education, regulations, policies and public health from data entered, verified, corrected or analyzed directly or indirectly. Homeland Security has recently been added to the list of users, including patient care providers, managers and staff, coders and patients themselves. Patients can make changes as necessary. Other users might include lawyers, employers, law enforcement and researchers. Government licensing agencies make policies that have been determined from the analysis of aggregate data gathered from medical records, in federal and state databases. Institutional users such as hospitals or clinics, depend on the Data Quality Management Model for adequacy and appropriateness of care determined by medical review organizations and the effectiveness of healthcare services reimbursement guidelines enabling the coding and billing departments to receive payments for their services. Research organizations use data to aid in experimental patient care and keep

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