Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Health Care Settings The Places Where Care is Delivered
Lecture:Departments and services
Interrelationships between health care organizations
Medical data use and impact
Slide content:Information Management varies Examples Admitting Medical records Information technology United Hospital Fund, 2008; Medicare Payment Advisory Committee, 2004 13
Slide notes:The management structure of information departments varies depending on the health care organization. Some have a management-level officer who reports directly to the CEO; in others, the managers of individual ancillary departments have a department director who reports to the COO or designate. Admitting is responsible for obtaining initial information from the patient, including demographic data, payer information, and reason for admission. They obtain general consent for admission to the hospital and agreement to pay for services not covered by the payer. This department also obtains acknowledgment that the patient has received information about the Health Insurance and Portability and Accountability Act (HIPAA) . Admitting may also ask patients if they have or would like to complete an advanced directive for care. Medical records departments provide oversight and overall management of the patients record, ensuring all compliance and legal requirements are maintained. In the past, the patients medical record was in a paper format. Today, provider organizations are shifting from paper to an electronic format, which allows easy access and retrieval of the patient record for immediate patient care activities as well as post-care activities such as billing, audits, and research. Although the basic function of the medical records department has remained constant, the staff skill set has transitioned to meet the needs of working with electronic data. Medical records works closely with the information technology department with the oversight and maintenance of the electronic patient record as well as with deployment of these systems. 13