Being a Medical Records/Health Information Clerk

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  • Edition: 3rd
  • Format: Paperback
  • Copyright: 2003-05-13
  • Publisher: Pearson

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Supplemental Materials

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Unlike other available books on medical recordswhich focus onmanagementof HIM departmentsthis one is especially designed for entry-level health information/medical recordclerks.It orients learners to the essential step-by-step procedures for being a medical records clerkfrom the importance of confidentiality to filing.KEY TOPICSSpecific chapter topics cover the health information management department, number and filing methods, processing medical records, assembly and analysis of the medical record, physician incomplete area, confidentiality and release of information, and other medical record clerk functions.For directors, managers/supervisors of HIM departments in hospitals, physicians offices, and outpatient clinics; and also for use in hospitals, and for anyone maintaining medical records.

Author Biography

Kathryn McMiller, RHIA, is an independent Health Information Management consultant based in Southern California. She has over 24 years experience in HIM, the last eight years as a consultant specializing in interim HIM department assessments and interim management and computer system installation project management. Kathryn has worked in hospitals ranging in size from 110 to 1,000 beds in various parts of the country.

Table of Contents

1. Being a Medical Records/Health Information Clerk.
2. The Health Information Management Department.
3. Number and Filing Methods.
4. Processing Medical Records.
5. Assembly of the Medical Record.
6. Analysis of the Record.
7. Physician Incomplete Area.
8. Confidentiality and Release of Information.
9. Other Medical Record Clerk Functions.


As the requirements for more and diverse types of documentation in medical records increase, the role of the Medical Records/Health Information Clerk in keeping the Health Information Management Department functioning becomes more and more critical. It is the intent of this text to provide basic information that will make the entry-level Medical Records/Health Information Clerk immediately effective.Chapters 1 and 2 provide an overview of the Medical Records/Health Information Clerk function and the Health Information Management Department. Chapters 3, 4, 5, and 6 teach the student filing and retrieval, record processing, assembly, and analysis. Chapter 7 discusses working with physicians in the Physician Incomplete Area. Chapter 8 deals with confidentiality and release of information, and Chapter 9 discusses other functions to which a Medical Records/Health Information Clerk may be assigned. Each chapter discusses computerization of documentation and the functions of a Health Information Management Department, where applicable.The text ofBeing a Medical Records/Health Information Clerkis designed to be used as a reference. Each chapter begins with a vocabulary of pertinent terms used in the chapter and specific objectives of the subject matter. Frequent headings and subheadings are identified throughout each chapter. The summary reviews the main points of the chapter. Learning activities at the end of each chapter give the student an opportunity to put into use the ideas discussed.Examples and opinions expressed as to the most effective means of performing a function are the author's opinion based on training, experience, and networking with colleagues. Methods for performing health information management functions vary based on individual Health Information Management Department demands, and no attempt has been made to illustrate all methods.

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