Medical Records Management Systems Note

Health Information Management Systems (medical records)

The hospital-wide system, The Master Patient Index, “may be considered the most important resource in a healthcare facility because it is the link tracking patient, person, or member activity within an organization (or enterprise) and across patient care settings” (Practice brief: master patient (Person) index (MPI)—recommended core data elements, 1997). The medical record number key data element is on every patient who received services at the facility. The Health Information Management Department staff pulls the information into the coding system, or record tracking system.

Coding software like Codefinder by 3M captures data, translate, and transmit the data. 3M describes the Codefinder as,

Computer-Assisted Edition first analyzes and interprets text from multiple documentation sources created during a patient’s hospital stay, including electronic records and dictated and transcribed reports. Robust terminology mapping tools link specific textual data required for coding to the logic-based coding paths of the 3M Coding and Reimbursement System. Coders are prompted with suggested codes or immediately advanced as far as possible through the software’s expert logic paths (3M Introduces Computer-Assisted Coding Solution, 2008).

Release of Information Systems

Once a request for medical records is valid the request is entered into they system, along with the requestor type. Certain requestors are required to pay, and others are not. The software program based on the requestor type categorizes the payment type. If the chart is voluminous a ‘prepay’ is flagged for payment. Once the information is entered, the chart is requested, and the tracking component in the system is switched to denote that the record has been forwarded for copy, or in the copying process. Once the record is copied the bill is generated automatically based on the number of pages copied. The shipping stamp, and address label is printed off automatically corresponding to the weight of the estimated number of pages.

3M Introduces Computer-Assisted Coding Solution. (2008, August 5). Retrieved May 29, 2009, from 3M: http://multimedia.mmm.com/mws/mediawebserver.dyn?6666660Zjcf6lVs6EVs66SMSrCOrrrrQ-

Practice brief: master patient (Person) index (MPI)—recommended core data elements. (1997, Jul/Aug). Retrieved May 29, 2009, from American Health Information Management Association: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_000073.hcsp?dDocName=bok1_000073