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History of Medicine and Medical Records
1. Describe the first surgical procedures on “record”.
Amputations & trephination
2. Explain how medical procedures were recorded in:
a. prehistoric times
b. ancient Egypt
a. prehistoric times - Paleolithic Drawings, paintings incaves
b. ancient Egypt - Papyrus & stone
Discuss the major contributions of:
A. ancient Greeks
B. ancient Chinese
C. ancient Arabians
D. ancient Romans
A. ancient Greeks - Established temples of healing, Harvested & prepared medicinal roots, serpent entwined around a staff, confidentiality
b. ancient Romans - Public health_ Medical “news” was read aloud in the streets, function of artieries, birth of anatomy
c. ancient Chinese - Yin / Yang, Acupuncture, Performed some surgical, procedures, including cleft lip repair
d. ancient Arabians - Distinguished smallpox from measles, pharmicueticals
(this multiple choice question has been scrambled)
Name the “Father of Medicine” and explain why he is so-named.
- Hippocrates -
- First to separate superstition from science_
- Developed the “Hippocratic Method” 1_ Observe patient 2_ Make diagnosis 3_ Watch course of illness 4_ Help nature overcome illness
Name two activities practiced by Hippocrates that are part of current medicalrecords practices in the U.S.
Detailed records and confidentiality
Explain the major difference between the medical records kept by the Greeks and those kept by the Romans, and explain the significance to health records of today.
- Romans had public records; Greeks had private records of healthcare practices
- Today we have more accurate tracking
7. Discuss the contributions each of the following made to the field of medicine, and the significance of each:
- Avincenna - pharmacueticals
- Crick-foudned DNA starnd
- Curie - radiology
- daVinci- science/paintings & autopsy
- deBarkey -
- Rhazes- secure, alcohol to cleanse wounds
- vanLeeuwenhoek - microscope
- Paster -Pastuerization
8. What event occurred during the Renaissance that changed medicine from superstition to a science?
- Monastic medicine kept the “flames of knowledge” alive in the West
- _ Monks & nuns – monastic (humanitarian) medicine & Renewed interest in learning, many scientific discoveries
- _ Development of universities, medical schools_
9. Explain why medical advancements often occur during times of war.
Opportunity to see many injuries and practice emergent medicine care and repairs
10. Discuss the role of events such as the development of antibiotics, anesthesia, minimally-invasive surgery, vaccines and gene therapy in improving health and life expectancy
- Arabic medicine lead to pharmicuticals
- Alcohol to cleasnse lead to surgery and anesteia
- Renissance develoed school/role of the heart helped life expectancy
11. Describe how the medical “advancements” of the 17th through 19th centuries paved the way for the medical advancements of the 20th and 21st centuries.
William Harvey determined how blood circulated through the body. Anton van Leeuwenhoek used a microscope and discovered red blood cells, bacteria, and protozoa. Edward Jenner invented vaccination after discovering the relationship between cowpox and smallpox. New drugs, including digitalis, were developed, and vaccination. As a result of some of the above developments, most notably antibiotics and vaccines, child and young people's mortality decreased drastically.
12. Describe the origin and symbolism of the AMA symbol and the caduceus
AMA symbol- The ambiguity of the serpent as a symbol, and the contradictions it is thought to represent, reflect the ambiguity of the use of drugs, which can help or harm, as reflected in the meaning of the term pharmakon, which meant "drug", "medicine" and "poison" in ancient Greek.The staff has also been variously interpreted. One view is that it, like the serpent, "conveyed notions of resurrection and healing"
The caduceus is also a recognized military symbol of commerce and negotiation, where it was sometimes associated with alchemy and wisdom.
The Health Information Management Profession
1.Describe the purpose of the organization founded by the American College of Surgeons on Cot 11, 1928?
Oct. 11, 1928 – Medical records workers attending the ACS meeting formally created the Association of Records Librarians of North America (ARLNA)
Purpose: to elevate clinical records-keeping
2. Describe the factors that influenced the development of the HIM profession.
- 1910: Carnegie Foundation commissioned astudy of the quality of medical education inthe US
- Findings: many and significant flaws and in consistencies in U.S. medical schools, better develop record management
3. Name the first president of the organization now known as AHIMA?
Grace Whiting Myers
4. What is the primary purpose of the AHIMA?
To foster the professional developments of its members through education, certification and lifelong learning.
5. Discuss the general intent of AHIMA's mission statement
To be the professional community that improves healthcare by advancing best practices and standards for health information management and the trusted source fr education, reasrch ad profesional credentialing.
6. Discuss the general intent of AHIMA's code of ethics
all members of AHIMA are expected to act in an ethical manner and comply with all lawsm regulationsand standards governing the practice of health informatin management.
7. Describe the role of the Commission on Accreditation for Health Informatic sand Information Management Education (CAHIIM)
- Mandates HIT & HIM Program content
- Accredits degree programs
8. Role of Commission on Certification of Health Informatics and Information Management(CCHIIM)?
- Through certification, the CCHIIM ensures the competency of professionals practicing health informatics (HI) and information management(HIIM) worldwide
9. Name the 8 certifcations awarded by CCHIM
- Certifications Awarded (all are exam-based)
10. Name the Cont Ed requirements for each of these certifications:
CCA CCS CCS-P RHIT RHIA
- RHIA(Registered Health Information administrator) 30 CEUs per 2-year reporting cycle*
- RHIT(Registered Health Information Technician)20 CEUs per 2-year reporting cycle*
- CCS or CCS-P(Certified Coding Specialist-physician) 20 CEUs per 2-year reporting cycle*
- CCA(Certified Coding Associate) +10 CEUs per cycle
11. Identify the organizational structure of AHIMA, and describe the basic function of each:
Council of Certification
- Board of Directors
- Elected by AHIMA members
- Conducts the business and professional affairs of the organization
- Executive Director
- Appointed by Board of Directors
- Oversees the business of the organization
- House of Delegates
- President + other elected officers
- Conducts business annually in conjunction with the association’s national convention
12. Name of official publicaiton of AHIMA
AHIMA: Journal of AHIMA
13. Name the state health information management association for Texas health information management professionals and explain how one becomes a member of this organization.
- TxHIMA: TxHIMA Journal
- TxHIMA is a CSA (Component State Association) of AHIMA and when one joins AHIMA they automatically become a member of the CSA of choice.
14. Describe the benefits of membership in professional associations such as AHIMA and TxAHIMA.
- Access to CoP
- FORE library
- Acess to state association
- Access local association
- Reduced registration fees at AHIMA related seminars, Workshops and publications
15. List and describe some of the roles of HIM professionals in today's health care environment?
16. Describe the purpose of AHIMA's "Community of Practice"?
Provides oppurtunities to contact other members for quick problem-solving, support, advice and career-building tips and opportunities.
17. Describe the purpose of
a. AHIMA Fellowship program
b. AHIMA Foundation (F.O.R.E.)
- a. The purpose of the Fellowship program is to:
- Recognize significant and sustained contribution to advancement of the Health Information Management (HIM) discipline through meritorious service, excellence in professional practice, excellence in HIM education, and advancement of the profession through innovation and knowledge sharing.
- Provide an incentive for members to contribute to the advancement of the profession.
- b. AHIMA Foundation (F.O.R.E.)
- To be the preeminent foundation in health information education, leadership, policy and research.
18. Identify the full name and major focus of each of these health information associations:
- American Association for Medical Transcription (AAMT)
- The goal was to implement a standard for content measurement that health information management (HIM) practitioners can use to evaluate in-house transcription staff and external transcription service suppliers.
18. Identify the full name and major focus of each of these health information associations: AAPC
American Academy of Professional Coders
This renowned medical coding association offers certification programs in Coding, Auditing and Compliance.
18. Identify the full name and major focus of each of these health information associations:
Association for Healthcare Documentation Integrity
purpose is to protect the integrity of patients’ health information through continuous workforce development and the support of practitioners and industry partners.
18. Identify the full name and major focus of each of these health information associations: HIMSS
The Healthcare Information and Management Systems Society (HIMSS) provides leadership in healthcare for the management of technology, information, and change through member services, education and networking opportunities, and publications.
18. Identify the full name and major focus of each of these health information associations: NCRA
National Cancer Registrars Association
primary focus is education and certification with the goal to ensure all cancer registry professionals have the required knowledge to be superior in their field.
Current Trends in HIIM
Current Trends in HIIM
1. In general terms, describe how the transistion to electronic health records systems has changed the HIM environment and the role of HIM professionals.
Less concerend with paper forms design and focus instead on developing good user interfaces for electronic medical records
2.a Revenue Cycle Management
How facilities can move from managing the revenue cycle by department to an interdisciplinary approach to gain significant improvements on the timely flow of revenue.
2.b Compliance Management
Management of the comprehensive cycle of people, processes and systems whose function is to facilitate the flow of patient data along each step of the revenue cycle.
2.c Patient Information Coordinator
– Coordinate information provided to patients and their families / caregivers
– Ensure that patients receive appropriate, timely, accurate health information about the services they receive
2.d Recovery Audit Contractors
• Perform external coding audits in order to identify miscoded bills submitted to federal government
2.e Regional Extension Centers
• Employ consultants to train and coach small providers on EHR system implementation
2f. RHIO managers –
Regional Health Information Organizations
– Purpose: governs health information exchange among them for the purpose of improving health and care in the community
4. Why should patients maintain a PHR?
patient care accuracy, reduce test redundancy, access to data
4b. Do parents of adult students have the right to access the student's PHR?
No. To access another adult’s information: Have the person you are caring for submit written authorization to his or her doctors’ and healthcare facilities.
4c. Under what conditions might the health care provider be justified in sharing the student's PHR information with his/her parent's?
Hospitals can share information with family members without your authorization if you are unable to consent and a family member (such as spouse, parent, or child) is involved in providing your care. For example, your spouse or child may be involved in caring for you following a hospital stay (by helping you in and out of bed, to bathe, changing bandages, and similar activities). You can simplify things at the time you are admitted to the hospital (or nursing home) by specifying which family member you want to receive information about you.
6. Describe the role of HIM professional in these forecasted trends:
- Forecasted trends
- – Increasing standardization
- – Increasing regulation (Compliance Mgr)
- – Increasing and improving technologies
- – Higher volume and detail of data
- – Patient-centered and family-centered healthcare
- – Personal health records (PIC)
- Will become more comprehensive and longitudinal Patients will by necessity have to have access to all of their health information in order to maintain
7. Describe steps the HIM professional should take to remian competitive in HIM?
engage in programs of lifelong learning
HIM professionals should learn new skills in areas such as :
- – Data analytics
- – Project management
- – Health informatics
- – Health information technology systems
- – Data management
- – Privacy
- – Security