Health records contain patients’ medical histories and courses of treatment. These may include doctors’ notes, forms for prescribed medications, input from other members of the treatment team, or test results. These records serve as crucial information for providers to make informed decisions about patient care and treatment. They also track the overall health status of individuals over time.
Health information management (HIM) professionals manage both the documents used to record information and the information within them. For example, the documents might be paper or digital. The information might include diagnoses, treatments, medications, immunizations, and other health-care data and history. HIM professionals also provide guidance and expertise to health professionals in other organizations and care settings.
Duties vary but, in general, HIM professionals:
- Oversee the use and management of health information systems, including electronic health records (EHRs)
- Translate information from paper files into digital records
- Assign accurate codes to medical diagnoses and procedures, for billing and statistical purposes
- Convert patient diagnostic and intervention information into a standard format using an international classification system and Canadian coding standards
- Make sure patient clinical records are complete, accurate, and secure, yet can be retrieved on demand (as appropriate)
- Identify and run data quality checks on records and databases
- Secure and release patient information as per Alberta’s Health Information Act
- Collect other information about patients and their hospital stays to generate data about the patient population
- Use computer software to manage health data for planning, research, and education purposes
- Manage clinic electronic medical records
- Contribute to health research initiatives by providing accurate and timely health data
- Stay informed about Canadian standards and practices for managing health information