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Health Information Management

Health Information Management professionals are specialists in data distribution, using computer software applications, word processing, database applications, and electronic routing systems to send data and files to the appropriate individuals (in-house and external locations) to keep medical records up-to-date, coding accurate, billing current, and a steady work flow going. All this is essential to efficiently managing large, or small health care facilities. If you want to pave the path to a solid career in the healthcare industry learn about HIM and how the health information department (usually in hospitals) utilizes database management systems to create data for medical records.

HIM Professionals

HIM stands for Health Information and Medical Records Management:
Contrary to what many believe, HIM professionals are not medical transcriptionists, or medical coders (although they go hand-in-hand!), rather they are experts in the field of patient health information, computer sciences (IT) technology, and medical database administration and record management. 

What is A Medical Record?

A medical record, health record, or medical chart is a systematic documentation of a patient's medical history and care. It contains useful information stored on different types of media and characters, such as letters, numbers, or a combination thereof, for operational or legal purposes. Once hospitals and medical practices have converted to Electronic Health Records (EHR) the demand for HIM Professionals will instantly increase, probably double, or triple.

What is Database Management?

Databases consist of files, records, fields, columns, and characters. Managing, storing, retrieving, and protecting databases falls well within the HIM department personnel scope of practice. To accomplish this task they usually utilize a Database Management System (DBMS). DBMS lets them create, store, modify, sort, and retrieve the data.

HIM/Technical English Research Paper:
Language and Culture of Medical Coders

Re: Language and Culture of Medical Coders«
from: CarolE on Yesterday at 03:04:32 PM

I am a HIM student at Davenport University. I presently am taking a Technical English class and have to write a research paper about the language and culture of Medical Coders. I would appreciate anyone from the Health Information profession to answer some or all of these questions and return them to me. The questions are listed below. I will need your name as I have to have this information APA cited. Thank you.

Carol Ewing
Davenport University HIM Student

Research Questions For Medical Coders:
1. What would you say is the most important aspect of working in the coding area of the Health Information Department?
2. Do you think that the other areas of the department understand a coders job really includes?
3. What are the top five areas you would suggest so a non medical person could understand the coder's language and culture in a Health Information Department?
4. What types of coding do you have to complete: inpatient, outpatient, laboratory, emergency , etc. or everything?
5. How many coders are there within your health information department?
6. What is the most important advise you would say to a future medical coder?
7. For other health information department employees:
8. What do you think the coder's job includes?
9. Were you ever a medical coder?
10. If no, would you be able to complete medical coding if your employee requires it?
11. If yes, why did you decide to move out of the coding area?
12. Which area did you move into?
13. Do you have much communication with the medical coders in a normal work day?
14. How are some words that you would use to describe the language of a coder?
15. How is the language that coders used different from those in other areas of the HIM department?
16. What are some words that you would use to describe the culture of a coder?
17. How is the culture of the coders difference from those in other areas of the HIM department?
18. List some examples:
19. Name some of the different type of areas within the HIM department?
20. What is the job description for a medical coder?
21. What type of education requirement do the coders in your place of employment have?

Reply #1 on Medial Billing Community:  Yesterday at 05:44:16 PM »

1.) Training, practice, experience, goal focus, business minded, punctuality, dedication, commitment, meeting deadlines, honesty, integrity.

2.) No. I believe other departments such as clinical nursing staff, health care technicians, allied health care professional, even doctors do not understand the scope, and full breadth of a medical coder's job.

3.) Plays a vital role in the patient healthcare setting, reviewing the patient’s charts, storing permanent medical files, documenting birth records/ newborn children birth certificates in hospitals.

4.) As a medical assistant, very simple coding-related tasks, such as circling codes on the patient encounter form, making sure the visit will be properly billed.

5.) Working in a solo-medical practice, there were none. Coding and billing was done by the medical office supervisor, and administrative medical assisting staff (back office).

6.) Get proper training, communicate with your instructors, find a mentor, land a medical coding job in an area you like, work your way up, participate in workshops, networking, and continuing education classes.

7.) Not a Health Information department employee.

8.) A medical coder's job includes attention to detail, matching diagnoses, and office visit (complexity), medical equipment and supplies with specific, matching alpha-numeric codes, which then go to the medical billing office.

9.) No.

10.) Only with additional training in coding procedures.

11.) I preferred working directly with medical and health care providers on the clinical floors.

12.) Medical assisting, web developing, and web design.

13.) No, except handing over completed patient medical charts, with the encounter form attached and initialed by the doctor to the medical office manager (who did the coding).

14.) I would best describe it at "industry specific lingo".

15.) I believe the medical coders language contains medical terminology, diagnostic terms, and words related to health care insurance processing, and claims submission, while the HIM department uses terminology related to computer sciences, database management, software input- and output devices, and patient records management. However, in order to keep the workflow going, both speak the lingo of International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), and also must understand proper use of medical terminology, diagnostic terms, and various terms related to the health insurance industry, and medical office admin areas.

16.) While many quite successful medical coders have been trained right on the job, health informatics or medical informatics requires education in IT information science, computer science, and health care, medical records administration.

17.) Both, medical coders and health information department personnel are a vital part of the healthcare industry as a whole.

I believe that what sets them apart is that medical coders mostly deal with (examining) patient charts and insurance plans to make sure that the doctor gets paid for services, while the HI department deals with creating and managing very large patient record databases via computer input devices, and software programs, and storage of medical records in digital format, and print.

Medical coders often have to contact the HI department to obtain copies of a medical records. I feel medical coders are business managers, and consultants by nature, while health information department members are more of technical and computer gurus by nature.

18.) Hot coffee, desks of paperwork, pencil holders, telephone, vs. computer screens, CPUs, mouse pads, and FAX machines.

19.) Medical records processing and storage, medical record review, medical record distribution, forms management and research, release of information.

20.) The job of a medical coder includes interpreting patient's medical charts and assigning the appropriate diagnostic and procedural codes for reimbursement. They use the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) which is accepted and used world-wide.

21.) 2 years of experience and certification.


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