3.02 Understand Health Informatics

MEDICAL TRANSCRIPTIONIST

MEDICAL RE

CORDS

ADMINISTRA

TOR

MEDICAL RECORDS TECHNICIAN

SECRETARY/RECEPTIONIST

HEALTH INSUR

ANCE

SPECIALIST

Health Informatics:Healthcare careers and job duties that document patient records and health information

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Health Informatics:Health information systems that operate between healthcare facilities

Integrate all medical records and insurance requirements into one system

Follow procedures for handling information to ensure patient privacy and security

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Health Informatics ProfessionalsCareer Responsibilities

1) Analyze patient information

2) Abstract and code patient information

3) Document patient information

4) Communicate patient information

5) Manage health information systems

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Health InformaticsCareer Responsibilities

1) Analyze 1) Analyze Patient Information:Patient Information:

Collect, review, and evaluate patient information Report and distribute the information within legal guidelines within healthcare systems and insurance companies

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Health InformaticsCareer Responsibilities

2) Abstract and2) Abstract and CodeCode Patient Patient Information:Information:Abstracting refers to collecting information from a medical record.

Coding refers to the assignment of a code to each of the patient’s diagnoses and procedures for the purpose of reimbursement

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2 Types of Coding:ICD-9-CMs are Diagnosis codes

CPTs are Procedure & Services codes

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Diagnosis CodesDiagnosis CodesICD-9-CM CodingUsed to code the DIAGNOSIS

Identify the main term in the DIAGNOSIS

Review sub terms, cross-reference, verify and assign correct numerical code

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Example: Essential hypertension

Example: Essential hypertension ICD-9 401.9

Diagnosis CodesDiagnosis Codes

ICD-9-CM Coding

Main Term in DiagnosisMain term – condition causing the patient to be sick.

Example: Urinary Tract InfectionInfection is the main term in this

diagnosis.

Review sub terms, cross-reference, verify and assign correct numerical code

Urinary Tract is the sub term ICD-9 is 599.0

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Complete the ICD-9-CM Coding using the internet

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Procedure Codes

CPT CodingUsed to code MEDICAL PROCEDURES AND SERVICES

Identify the main procedure or service

Review sub terms, cross-reference, verify and assign correct 5 digit numerical code

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Example: X-ray pelvis, 4 views

Example: X-ray pelvis, 4 views CPT code 72190

Procedure Codes

CPT Coding Main Procedure or Service provided

Example: Needle core biopsy of lungBiopsy is the main procedure or service

provided

Review sub terms, cross-reference, verify and assign correct 5 digit numerical code

Sub Terms are Needle core, lung CPT code is 32405

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Complete the CPT Coding

using the internet3.02 Understand health informatics 13

Health InformaticsCareer Responsibilities Documenting

3) Document 3) Document Patient Information:Patient Information:Documenting refers to recording and transcribing patient information and health information.Includes completing and processing insurance forms.Must follow legal guidelines and confidentiality.

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Health InformaticsCareer Responsibilities Documenting

Medical Transcriptionist:Medical Transcriptionist: Works independently and transcribes health information dictated by physicians and other healthcare professionals into the patient’s medical record

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Health InformaticsCareer Responsibilities Documenting

Requires:knowledge of medical terminologyunderstanding of anatomy, physiology, and disease processes

familiarity with pharmacology and laboratory tests

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Health InformaticsCareer Responsibilities Documenting

Health Insurance Specialist:Health Insurance Specialist:

Completes and processes insurance

forms.Determines the information needed by insurance companies for reimbursement.

Assigns ICD-9 and CPT Codes.

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Complete the Medical

Terminology

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Health InformaticsCareer Responsibilities Communicating

4) Communicate 4) Communicate Patient Patient Information:Information:Communicating refers to the exchange patient information and health information. Includes:

Filing records Using technology Scheduling appointments Completing medical records forms Maintaining accounting records3.02 Understand health informatics 19

Health InformaticsCareer Responsibilities Communicating

Medical Records Technician:Medical Records Technician: Files patient records (patient charts).

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Health InformaticsCareer Responsibilities Communicating

Ways to File Records:AlphabeticalNumeric

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Health InformaticsCareer Responsibilities Communicating Alphabetical:

Index all names first: Index all names by transposing so that the last name is the primary indexing unit, first name second and middle name/initial is third.

After indexing, follow strict alphabetical order.

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Health InformaticsCareer Responsibilities CommunicatingNumeric:

Uses numbers in various combinationsStraight-numeric, consecutiveTerminal-digit, the last digit is the primary unit

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Complete the Alphabetic/Index FilingStraight & Terminal Numeric Filing

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Health InformaticsCareer Responsibilities Communicating

Office Secretary/Unit Office Secretary/Unit Secretary:Secretary: Answers the phoneSchedules appointmentsMay work for one doctor or a group of doctors; or work at hospitals

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Complete Telephone EtiquetteScheduling Appointments

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Health InformaticsCareer Responsibilities Communicating

Admissions Clerk:Admissions Clerk: Completes medical record intake forms; Completes medical record intake forms; requires attention to details.requires attention to details.Collects personal and insurance Collects personal and insurance information when entering the Emergency information when entering the Emergency RoomRoom

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Health InformaticsCareer Responsibilities Communicating

Bookkeeper:Bookkeeper: Maintains accounting Maintains accounting records.records.Includes:Includes:

InventoryInventoryPatient accountsPatient accountsCash recordsCash recordsPayroll recordsPayroll recordsTax recordsTax records

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Health InformaticsCareer Responsibilities Managing

5) Manage 5) Manage Health Information Health Information      Systems:     Systems:Managing refers to being in charge of all the information systems used within a healthcare agency.Ensures timely and accurate.Follows regulations, guidelines, and confidentiality.

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Health InformaticsCareer Responsibilities Managing

Medical Records Administrator:Medical Records Administrator:Manages/in charge of all the information systems used within a healthcare agency like a hospital.Highest responsibility.

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Employment Opportunities in Health Informatics

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The End

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