HIM (Health information Management) ادارة المعلومات الصحية

1. HIM (Health information Management) ادارة المعلومات الصحية

2. * Team Members ( HIM, KAUH ) • Mona Al Babtain(Built Team). • Mosabih Al Nahdi (Built Team). • Jenan Al Sayegh ( Built Team). • ModiAlotibi (trainer). • Omar Al Harbi (trainer). • Ahmed ALOnaizan (trainer). • Sukainah Al Zuhair ( trainer). • Abdulaziz Al Dobaib ( trainer). • Wed Al Zahrani (Super User) • Rashod Al Khaibari (Super User)

3. What is cerner ? * ماذا تعرف عن cerner شركة تكنولوجيا المعلومات الصحية التي تتخصص في توفير أنظمة خدمية شاملة لمقدمي الرعاية الصحية والمنظمات الطبية بم فيها المستشفيات وذلك لإدارة ودمج جميع السجلات الطبية الإلكترونية والخدمات المحوسبة وتنفيذ جميع الخدمات الكترونيا وربط جميع الاقسام بنظام موحد يسهل خدمة المرضى المقدمة سواء من قبل الاطباء او مرافق اخرى بالمستشفى والتي تسهل وترفع من مستوى الرعاية الصحية المقدمة لتواكب التطورات الحديثة في المجال الصحي . It is international health care information technology corporation that specializes in providing completes systems for health care providers and medical organizations to manage and integrate all electronic medical records and computerized all patient services that providing by physician or other facilities in the hospital

4. What is e-sihi ? This abbreviation is related to Electronic System Integrated Health Information

5. Benefits * • Paper-light Hospital. مستشفى باوراق اقل حتى يتم التحويل كاملا الى النظام الالكتروني • Powerful Patient Chart Management. إدارة وتحكم اقوى لمعلومات المريض وحفظ سرية المعلومات ومتابعة السجل الطبي • Automatically identify and resolve patient chart deficiencies. والناتج ملف كامل وموثق التعرف تلقائيا وازالة القصور لنواقص سجلات المرضى • Reduce lost charts by offering powerful chart tracking solution. التقليل من ضياع الملفات الطبية واكمال نواقصها بنظام اتباع السجل الطبي الالكتروني المحكم والتدقيق الالكتروني . • Chart Coding Solution الترميز للسجلات الطبية الكترونيا بطريقة متطورة وسهلة وفعالة ومحكمة البيانات • Accurate Reports .( Studies , Statistics ..etc. ) تقارير دقيقة (دراسات وإحصائيات .. الخ)

6. *Issues and Concerns . • Approve Purchasing orders for: • 3M coding solution • New Dictation system • ICD 10-AM Training • Archiving system in KKUH for inactive files only. • ROI • ROI as a part of HIM • New clear policy for ROI.

7. * ( HIM, KAUH SULOTIONS)

8. Introduction • Cerner HIM is a major Health Information Management offering that is focused on the attainment of productivity gains and management control over all operations performed by medical records personnel. This solution provides an integrated set of functionality committed to the elimination of redundant data entry and the minimization of manual activities. It is designed not only to meet the system needs of traditional, paper-based medical records departmental operations, but also to support the parallel or future migration of paper to electronic media-based medical records via Cerner’s Power Chart solution.

9. |Chart Tracking • Use Tracking to manage the movement of patient chart media throughout your institution. You can create new chart volumes using the patient chart (PC) or unit record (UR) system of filing. You can perform an inquiry to locate a specific chart volume, or record the movement of a group of charts from one location to another. Chart Tracking combines and streamlines the functions of three earlier applications: Create Volume, Chart Inquiry, and Chart Location Update. • Chart Tracking operates in two inquiry modes. You can select a patient and view the patient's visits with a list of each visit's corresponding chart media, or you can select a location and view a list of all the chart media from various patients currently at the location

10. |Chart Tracking Search by Patient 1.Click on Find Patient button. 2.You can search for a patient by: • Name • DOB • SSB • MRN • FIN •Facility Search by Location 1.Click Inquire by Location button. 2.Click the drop down menu under Chart Locations. 3.Click the location view you are searching to view the list of locations. 4. Double click on a location to view the charts in that location.

11. |Patient Information Request PIR • Use Patient Information Request to process internal requests for patient charts. Provided that your system manager has set up your system to permit batch request, you can enter requests for a set of one or more patients' charts to be sent to a common requester at a common location. For multi-patient requests, enter the requests individually to add them to a list of charts that are processed and sent in batch. You can remove a chart from the list before sending the batch request. Sending a request creates a log that reflects the name of the requester, the date of the request, and the reason for the request.

12. Physician Deficiency Analysis Use Physician Deficiency Analysis to view and manage current information regarding chart completion deficiencies charged to a particular physician. After you select a physician, you see a list of patients whose charts are incomplete due to document requirements for which the selected physician is responsible. The list is in spreadsheet format and shows various information about the patient and the chart or visit. You can filter the list to include only charts with document requirements that are overdue and are cause for the physician to be termed delinquent. Physician Deficiency Analysis can be used to suspend physicians who have not completed their deficiencies within the specified timeframe.

13. Chart Coding Chart Coding to capture grouper, diagnosis, and procedure codes and related information for a patient visit. Chart Coding enables you to send patient demographic information to an encoder, receive coded data back from the encoder, and complete the coding task for an encounter. If you enter a HCPCS or CPT code, the system automatically supplies the correct APC code. Chart Coding also offers a variety of other options. You can enter coded data directly, without interfacing to an encoder. You can print coding summaries. If your organization is capturing abstract data from charts, you can relate certain codes to fields in the abstract form. You can also access the Cerner HIM Task Queue to view and process coding tasks in the queue.

14. Patient Analysis Patient Deficiency Analysis to view a list of chart deficiencies related to a particular patient for a single visit or for multiple visits and to update the status of documents on the list. You can set your preferences to retrieve information about a single patient visit or for multiple visits. By selecting a patient and a visit, you can monitor chart completion activities and update statuses. You also can create notes or holds and print a deficiency slip to affix to the patient chart.

15. Request Queue • Use Request Queue to view all of the Patient Information Requests (PIR) for charts and documents that have been logged into the system and their current state of completion. You can limit the search to charts requested by a particular requester or those requested for a particular patient. The Request Queue shows only internal requests • You can process and update requests in the queue, attach notes to individual requests or to patient visits, and print pull lists and request slips. An extremely flexible display offers an in-depth analysis of the details of each request, and a behind-the-scenes log records the names of those who processed or modified each request. • Request Queue works closely with Patient Information Request and Request Manager/Request Management. You enter a request using the appropriate application, then view the logged requests in Request Queue and update them.

16. Access Management-HIM – Request Management • The Request Management perspective processes external requests for patient charts. Use the Request Management perspective to enter a request for a chart if the requester is not a staff member. This includes a patient who is requesting his or her records, an insurance company, an agent of the court, or any incidence whereby portions of the medical record are copied to be transported outside of your institution, whether by paper or electronic media. • The Request Management perspective logs a request into a queue where it waits to be processed and records the pertinent data for the request for audit purposes. Within the Request Management perspective, the Request Queue view is used to inquire about existing requests and their status. You can check on the progress of an entered request or make modifications to it. You can also view a list of a particular healthcare professional's chart requests or a list of all requests made for a particular patient's records.

17. . Conclusion This booklet includes instructions and information's about HIM solutions (medical record department) in Citrix system, and solutions covered by the section with some clarifications regarding the patient's chart location, requesting, coding and so on. I wish success for all the interest Preparation : Moudi Al Otaibi King Abdul-Aziz university hospital HIM department, transcription unit.

18. . I wish success for all the interest Preparation : Moudi Al Otaibi King Abdul-Aziz university hospital HIM department