This document discusses the purpose and function of health records. It defines a health record as a repository for patient healthcare data that documents details of care. Health records have primary purposes of patient care and secondary purposes like education and research. The document outlines various users of health records including care providers, patients, researchers, and government. It describes functions of health records like storing documentation, assisting with diagnoses and treatment selection. Data quality, security, flexibility, connectivity, and efficiency are important characteristics for health records. Electronic health records provide improved guidance for clinical problem solving compared to paper records.

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Health Information Management
Technology:
An Applied Approach
Fourth Edition
Chapter 2: Purpose and Function
of the Health Record

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Introduction
• A health record is a principal repository for data
and information about healthcare services
provided to the individual patient
• Documents the who, what, when, where, why,
and how
• Many people have multiple health records

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Other Names for the Health Record
• Patient records—inpatient setting
• Medical record—physician office
• Resident—long-term care
• Client records—ambulatory behavioral
health services

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Data vs. Information
• Data are basic factors about people, processes,
measurements, conditions, and such
o Facts
• Information is data that has been collected
and analyzed
o Meaning

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Health Information Management
• HIM professionals are responsible for
management of health records
• Traditional practice was collection of data in
paper forms
• New practice is the electronic health record
• Personal health record is initiated and maintained
by individual

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Purposes of Health Record
• Primary purpose is patient care
• Secondary purposes are related to
environment in which the healthcare
services are performed

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Primary Purposes
• Patient care delivery
o Document care provided
• Patient care management
o Examples include developing practice guidelines and
evaluating quality of care
• Patient care support processes
o Management of healthcare organization’s resources

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Primary Purposes
• Financial and other administrative purposes
o Determines payment
• Patient self-management
o Patient accesses health record

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Secondary Purposes
• Education
• Research
• Regulations
• Policy making
• Public health

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Users of Health Record
• Primary users are patient care providers
• Other users
o Accreditation organizations
o Licensing bodies
o Educational organizations
o Third-party payers
o Research facilities

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IOM Definition of Users of Health Records
“Individuals who enter, verify, correct,
analyze, or obtain information from the
record, either directly or indirectly through
an intermediary”

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Individual Users
• Patient care providers
o Physicians, nurses, other allied health professionals
o Document patient care
• Patient care managers and support staff
o Evaluate performance of staff
o Use aggregate data to improve future patient care

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Individual Users
• Coding and billing staff
o Assign diagnostic and procedure codes
o Submit bill to third-party payer
• Patients
o Access own health records
o Request amendments to health record
o Obtain copies of health record

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Other Individual Users
• Employers
o Occupational hazards
o Manage insurance for employees
o Disability claims
• Lawyers
o Protect legal interests of facility and care providers
o Used in medical malpractice cases
o Mental competence of individuals

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Other Individual Users
• Law enforcement officials
o Investigate gunshot injuries, child abuse and
neglect and other crimes
o Identify and locate suspects, fugitives and others
o In support of national (homeland) security
• Healthcare researchers and clinical investigators
o Evaluate effectiveness of treatment
o Make decisions about disease processes
and treatment

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Other Individual Users
• Health science publishers and journalists
o Aggregate information used to generate articles on
alternative medicine, preventative medicine and more
• Government policy makers
o Evaluate health of populations
o Reporting communicable diseases
o Reporting of gunshot wounds

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Institutional Users
• Healthcare delivery organizations
o Provide services
o Evaluate and monitor use of resources
o Seek reimbursement
o Planning
o Marketing
• Third-party payers
o Determine if documentation supports reimbursement
requested

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Institutional Users
• Medical review organizations
o Evaluate the adequacy and appropriateness of care
provided
• Research organizations
o Prove or disprove hypotheses related to disease
processes and treatments
o Experimental patient care
o Disease registries

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Institutional Users
• Educational organizations
o Students have hands-on education
o Case studies
• Accreditation organizations
o Improve quality of services provided
o Periodic survey
o Review patient records

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Institutional Users
• Government licensing agencies
o Certify facilities to receive funding
o Review records to confirm compliance with
regulations
• Policy-making bodies
o Used to make decisions related to healthcare
reimbursement, effectiveness of healthcare services
o Create federal and state databases

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Functions of Health Record
• Primary function
o Store patient care documentation
• Other functions
o Assist in assigning diagnoses
o Assist in choosing treatment

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Storage of Patient Care Documentation
• Quality
o Quality of information in record
o Sources of data
• Patient
• Patient’s family
• Healthcare providers
• Monitoring equipment
o Incomplete/missing information can compromise
patient care

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Data Quality Management Model
• Data application
o Purpose for which data are collected
• Data collection
o Processes by which data are collected
• Data warehousing
o Processes and systems by which data are archived
• Data analysis
o Processes by which data are translated into information

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Quality Characteristics
• Accuracy: Data are correct
• Accessibility: Data are easily obtainable
• Comprehensiveness: All required data elements included
o Patient identification
o Consents for treatment
o Advanced directives
o Problem list
o Diagnoses
o Clinical history
o Diagnostic test results
o Treatments and outcomes
o Conclusions and follow-up requirements

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Quality Characteristics
• Consistency: Data are reliable
• Currency: Data are up to date
• Timeliness: Data are recorded at or near the time of event
• Definition: Data and information is predefined
o Each data element defined and range of acceptable values
• Granularity: Attributes and values of data defined at
correct level of detail for the intended use
• Precision: Expected data values
• Relevancy: Data are useful.

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Data Quality Improvement
• Traditional approach with paper-based records
utilizes retrospective audits
• EHR data quality is built into information system
design so that quality data is collected real-time

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Security
• Balance legitimate need to access health record
with patient’s privacy
• Privacy: Right of individuals to control access
to their personal health information
• Confidentiality: Expectation that personal
information will be shared only for the
intended purpose
• Security: Protection of privacy of individuals
and confidentiality of health records

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Flexibility
• Data should be flexible enough to meet the needs
of all of the users
• Paper records cannot fully provide the required
flexibility for all users
• Electronic health records are flexible per
individual user need and customize how
information is displayed and presented

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Connectivity
• Connectivity refers to capacity of health record
systems to provide electronic communication
linkages and allow the exchange of health record
data among information systems.
o Disparate information systems within an organization
o Interoperability standards permit exchange of
information within a region or nation.

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Efficiency
• Improved with the EHR
o Access to patient records
o Collection of discrete data elements supports
efficient analysis

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Guidance in Clinical Problem Solving
• Properly formatted health record assists in
patient care
o Paper records
• Source-oriented health record format
• Problem-oriented health record format
• Integrated health record format
o Hybrid records
• Combination of paper and electronic records
• Difficult to locate all components of the record
• Duplicate HIM processes must be maintained

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Guidance in Clinical Problem Solving
• Electronic records
o New formats and functionality being introduced
• Results management
o Timely access to all test results improves quality
of care
• Order-entry/order management
o Computerized physician/provider order entry (CPOE)
has decision support

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Guidance in Clinical Problem Solving
• Clinical decision support
o Notify physicians of abnormal test results
o Assist in diagnosing and selecting treatment
o Access to reference materials such as pharmaceutical
formularies
o Analyze data