A 30-year-old male is admitted to the hospital after an evaluation in the emergency room. After undergoing a series of blood tests and a kidney scan he is diagnosed with HIV/AIDS. After three days of receiving intravenous fluids and antibiotics, he is discharged home in fair condition. The hospital uses electronic processes to retrieve and store patient records. If you were performing an analysis of this medical record, you would expect to find several documents and clinical evaluations. But before you do, you think about the application of The American Health Information Management Association (AHIMA) and its impact on documentation standards and how these types of cases may impact your career going forward. Explore the history of health information management (HIM) and the AHIMA organization and then answer the questions below. Make note of the definition for HIM, and review AHIMA’s history, mission, and future predictions. Then, discuss documentation guidelines developed by AHIMA, and how they would apply to the scenario described above. Describe how the recent and future technological changes in health records management has/will impact your chosen career path as a health care professional. You may use the AHIMA website as a resource (www.ahima.org).
Health Information Management (HIM) is a crucial aspect of the healthcare industry, encompassing the collection, organization, and protection of patient health records . In recent years, electronic processes have revolutionized the way patient records are managed, ensuring efficiency and accuracy in healthcare settings. This essay explores the history of Health Information Management and the role of The American Health Information Management Association (AHIMA) in shaping documentation standards. It also delves into the application of AHIMA’s guidelines in a specific medical scenario involving a 30-year-old male diagnosed with HIV/AIDS. Furthermore, the essay discusses the impact of recent and future technological changes in health records management on the career path of healthcare professionals.
History of Health Information Management and AHIMA
Health Information Management (HIM) is the practice of acquiring, analyzing, and protecting medical information essential for patient care, research, legal, and administrative purposes (AHIMA, 2021a). HIM professionals play a pivotal role in ensuring the accuracy and accessibility of patient records, contributing to improved patient care and healthcare decision-making. The American Health Information Management Association (AHIMA), founded in 1928, has been a driving force in advancing HIM (AHIMA, 2021b). AHIMA is a globally recognized authority in health information management and is committed to improving the quality of healthcare through effective management of health information. AHIMA’s mission is to empower people to impact health by providing leadership in health information management and the trusted source for HIM expertise. They work towards achieving this mission by establishing and promoting the standards of the profession, advocating for the value of health information, and providing education and resources for HIM professionals (AHIMA, 2021c).
Documentation Guidelines Developed by AHIMA
AHIMA has developed comprehensive documentation guidelines to ensure the accuracy, consistency, and integrity of patient health records (AHIMA, 2021d). These guidelines are essential for healthcare professionals to maintain a standardized approach to documenting patient information. In the scenario of the 30-year-old male diagnosed with HIV/AIDS, these guidelines would be crucial. AHIMA’s documentation guidelines emphasize the importance of complete and timely documentation. In the case of the HIV/AIDS diagnosis, the healthcare professionals should document the patient’s medical history, including risk factors, symptoms, and previous treatments. The diagnosis itself should be clearly recorded, along with any relevant laboratory results, such as CD4 counts and viral load measurements. AHIMA guidelines stress the need for documenting the treatment plan and its implementation. In this scenario, it would involve documenting the administration of intravenous fluids and antibiotics, the patient’s response to treatment, and any changes in their condition during the hospital stay. Discharge instructions and follow-up recommendations must also be accurately documented to ensure continuity of care (AHIMA, 2021d).
The Recent and Future Technological Changes in Health Records Management
The healthcare industry has witnessed a significant transformation with the advent of electronic health records (EHRs) and health information technology (HIT). These technological advancements have streamlined the management of patient records, enhancing accessibility, security, and interoperability (HIMSS, 2021). As a healthcare professional, the impact of these changes on one’s career path is substantial. EHRs enable healthcare providers to access patient information remotely, improving coordination of care and reducing errors. However, it also requires healthcare professionals to adapt to new systems and workflows. Training and proficiency in EHR systems have become essential skills for healthcare professionals (HIMSS, 2021). The use of data analytics and artificial intelligence in health records management can provide valuable insights for patient care and population health management. Healthcare professionals may find themselves collaborating with data analysts and technology specialists to leverage these tools effectively (HIMSS, 2021). The shift towards telehealth and remote patient monitoring has become more pronounced, especially in response to the COVID-19 pandemic. Healthcare professionals may need to adapt to virtual care settings and become proficient in telemedicine technologies to provide quality care while ensuring patient privacy and data security (HIMSS, 2021).
Health Information Management (HIM) is a critical aspect of healthcare, and organizations like The American Health Information Management Association (AHIMA) play a pivotal role in shaping documentation standards and advancing the profession (AHIMA, 2021a). AHIMA’s guidelines emphasize the importance of accurate and timely documentation, which is vital in the diagnosis and treatment of patients like the 30-year-old male with HIV/AIDS. The healthcare industry is undergoing rapid technological changes, with electronic health records and health information technology revolutionizing the way patient records are managed (HIMSS, 2021). Healthcare professionals must adapt to these changes, incorporating electronic systems and data analytics into their practice, and may even find themselves engaged in telehealth and virtual care. As healthcare continues to evolve, HIM professionals will remain at the forefront of ensuring the integrity and accessibility of patient health records, ultimately contributing to improved patient care and healthcare outcomes. Adaptation to these changes and adherence to AHIMA’s guidelines will be essential for healthcare professionals in their chosen career paths.
American Health Information Management Association (AHIMA). (2021a). About Health Information Management. Retrieved from https://www.ahima.org/about/about-health-information-management/
American Health Information Management Association (AHIMA). (2021b). Our History. Retrieved from https://www.ahima.org/about/our-history/
American Health Information Management Association (AHIMA). (2021c). Our Mission. Retrieved from https://www.ahima.org/about/our-mission/
American Health Information Management Association (AHIMA). (2021d). Documentation Guidelines. Retrieved from https://www.ahima.org/topics/documentation-guidelines/
Healthcare Information and Management Systems Society (HIMSS). (2021). Health Information and Technology. Retrieved from https://www.himss.org/resources/health-information-and-technology
Frequently Asked Questions (FAQs)
What is Health Information Management (HIM)?
Health Information Management (HIM) is the practice of acquiring, analyzing, and protecting medical information essential for patient care, research, legal, and administrative purposes. HIM professionals are responsible for managing and maintaining accurate and confidential patient health records.
What is the role of The American Health Information Management Association (AHIMA)?
AHIMA is a professional association founded in 1928 that plays a crucial role in advancing Health Information Management. It sets standards for the profession, advocates for the value of health information, provides education and resources, and empowers professionals to impact health through effective health information management.
What are the key missions of AHIMA?
AHIMA’s key missions include providing leadership in health information management, establishing and promoting standards of the profession, advocating for the value of health information, and serving as a trusted source for HIM expertise.
How do AHIMA’s documentation guidelines benefit healthcare professionals?
AHIMA’s documentation guidelines ensure the accuracy, consistency, and integrity of patient health records. Healthcare professionals benefit from these guidelines by having a standardized approach to documenting patient information, which enhances patient care, decision-making, and legal protection.
How has technology, such as electronic health records (EHRs), impacted healthcare careers?
Technology, including EHRs and health information technology, has revolutionized healthcare. It has improved the accessibility, security, and interoperability of patient records, making healthcare more efficient and accurate. Healthcare professionals need to adapt to these changes by becoming proficient in EHR systems and leveraging data analytics and telemedicine technologies.