Head of department: Ms. Shahrbanoo Pahlavaninejad

Health Information Management Department provides services to patients, physicians, hospital managers. It provides educational services, maintains the quality of medical and health services and patients' rights, and observes standards. It is one of the most important hospital wards with the following specific objectives:

  • Establishing an efficient system for maintaining a complete patient record.
  • Having statistics of diagnostic and clinical operations performed, analyzing and interpreting them.
  • Gathering scientific information from files and their medical reports.
  • Responding to legal correspondence to assist legal authorities in issuing judgments.
  • Assisting in managerial decision-making in the development of facilities and equipment of wards, etc., using statistics of patients.

 

Health Information Management Committee and Information Technology:

Qualitative review of the clinical file, issues and problems of the unit and establishing a connection between the medical, Paraclinical and administrative units related to the case will be done in this committee. The members of the committee are:

Head of the hospital

The hospital manager or his / her authorized representative, the physicians' representative, the health information manager as the meeting secretary, the hospital matron, the head of the hospital quality improvement office and other officials, as the case may be.

This committee is held every month and the minutes are sent to the esteemed Vice Chancellor for Treatment of the university.

Role and importance of clinical file:

  • A basis for planning and ensuring continued patient care
  • A communication tool between physicians and other staff involved in patient care
  • To prepare documentary evidence of the course of the disease and treatment of the patient
  • A basis for study, review and evaluation
  • For legal assistance and support to the patient, hospital and responsible staff
  • To provide information for use in medical expenses
  • Education and Research
  • The contents of the file are usually confidential and are not even available to the patient.

This field includes occupational classes whose employees range from the lowest occupational levels to the highest levels of health information management in health centers, hospitals, health information management departments of colleges and university headquarters, and various deputies of the Ministry of Health operate under the titles of technician, expert and expert in charge of health information management.

Responsibilities of Health information management:

  • Responsibility of the Health Information Management Committee to obtain the necessary policy and instructions from the relevant supervisor
  • Monitoring the units covered by admission, archiving, computer, coding and hospital statistics
  • Monitoring the entry and exit of files and their completion at the time of admission until discharge
  • Monitoring how to respond to legal complaints, review and research on improving medical records forms - working methods - equipment, location
  • Requesting and monitoring the preparation of all hospital file forms
  • Setting up a file control system for hospitalized patients
  • Monitoring of death certificate and birth certificate
  • Collaborating on monitoring file requests from different hospital wards
  • Delivery of files for research purposes
  • Monitoring the observance of administrative discipline of personnel
  • Following up of the supply Human Resources in the relevant unit
  • Planning, division of labor and, in the case of leave, replacement of staff in the relevant unit
  • Monitoring the performance and attitude of the covered employees
  • Recording and reporting all matters related to the relevant authorities, including requests, deficiencies and defects
  • Reviewing the statistics and reporting the actions of the relevant unit monthly to present to the superior authority
  • Preparing and collecting statistics of medical centers (hospital - clinic - clinic, etc.)
  • Preparing and collecting statistics of Paraclinical centers (laboratory - clinic - clinic)
  • Preparing and collecting hospital activities (fixed bed - active bed - hospitalized and discharged patient and ....
  • Elimination and following up defects in the health information management unit
  • Presenting statistics reports of therapeutic activity to various units and other institutions
  • Completing statistical software
  • Presenting Backup and maintaining statistical data
  • Participating in training classes and public meetings of health information management
  • Observing the principles of professional ethics and maintaining the principle of confidentiality of medical information
  • Maintaining the unit's own equipment related to the job being held
  • Accurate recording of identity information and identification of patients at the time of admission in HIS forms and programs
  • Completing all the forms requested by the competent authorities and sending them

Responsibilities of the Health Information Manager

  • Monitoring the correct way of coding diseases, actions and recording the relevant codes in the hospital information system
  • Investigating and research on improving medical records forms and the being responsible of the committee for compiling and organizing medical records forms
  • Following-up and research on work methods, tools, location of health information management unit
  • Recording the performance of physicians' visits, activities and clients of hospital wards in the Avab system
  • Sending information of patients registered in HIS to the SEPAS system
  • Monitoring the registration of activities and cases of other sections in the Avab system
  • Controlling the presence and absence of the employees of the sub-units and timely reporting of the absence of each of the employees of the unit
  • Preparing and adjusting the necessary statistics for the health authorities of the country
  • Participating in hospital committees and being responsible for the Health Information Management Committee
  • Setting up a file control system for hospitalized patients
  • Controlling and monitoring over the archiving of files according to the established methods
  • Monitoring the preparation and compilation of daily, monthly and annual statistics on the number of patients admitted and discharged and the dead in the hospital and their analysis and calculation of bed occupancy rates, etc.
  • Responding to correspondence related to the unit such as forensic medicine and other organizations using medical records and information in coordination with the Head or management of the center
  • Monitoring the work of employees under their supervision, evaluating and updating their information through training courses
  • Participating in job and management training courses
  • Paying full attention to the documents and instructions of the quality management system
  • Carrying out other tasks in the field of work according to the order of the superior authority

Medical Records Archive Unit:

As mentioned, medical records are a visible evidence of what has been done in the hospital and timely documentation of health care procedures performed on patients.

Therefore, medical records must be prepared, completed and arranged in the archive unit by its staff. In the case file, all documents related to special measures that have been performed for the patient in that medical center are maintained with an appropriate system. So everyone can access the maximum information in the shortest time in hospitals and health centers.

In health care organizations such as hospitals, one of the main sources of health care information is the patient's medical record and is considered as the most important and richest source of information. The patient's medical record is the most important tool for storing and retrieving information, analyzing health care. It represents all information related to the patient's health history, diseases, health risks, diagnoses, tests, examinations, treatments, course of the disease, response of the patient to treatment, following up, and so on.

Therefore, due to the importance of patients' information in health care, archives can be considered as hospital memory.

The archive location should be located on the ground floor, directly below the medical records section. The internal staircase for the passage of people and a dedicated elevator for transporting the file or other file transfer systems facilitate access to medical records and prevent waste of time and disorder in the work space. This design will be effective in better archiving performance. The health of workplace such as welfare facilities - lighting (indirect) noise - air conditioning - humidity (50-65%) heat (20-25) Fire warnings (walls and floors are fireproof) Cleanliness (Preventing dust from settling on files) Insects - Occupational diseases and their complications are important.

Responsibilities of the archivist:

  • Performing archiving of patients' files according to the determined method.
  • Separating files of hospitalized patients, outpatients and those with previous history.
  • Trying to protect patients' files.
  • Paying full attention to the documents and instructions of the quality management system.
  • Participating in training and general courses to enhance job skills.
  • Proper coding of diseases and procedures and registration of relevant codes in the hospital information system according to the instructions
  • Cooperating with the medical staff in the fields of research, qualitative analysis of medical records or relevant committees.
  • Scanning and registering traffic accident files on the relevant site
  • Responding to the client regarding the request of the case according to the regulations and with the coordination of the head of the department or management
  • Performing other duties in the field of work according to the opinion of the superior authority.

 

Reception:

The reception is the first station in the cycle of providing medical services. Clients may not deal with many parts of the hospital during their stay, but they will definitely deal with the reception department. So the memories that come to mind from this brief encounter will be present with them throughout their presence in the hospital and perhaps throughout their lives, and on the other hand, this encounter can change the mindset of the patient or his companions about the hospital and the hospital management. In fact, reception can be considered as a hospital showcase.

Since the staff of the reception department is the representative of the staff of each medical unit, their selection should be done carefully. The type of personnel approach, the speed of work, location and arrangement of the reception unit are important.

Its staff work in three shifts in rotation in all hours of the day and night, and are shared with the cash unit in the evening and night shifts. One person serves in each shift in this unit.

Statistics:

Statistics are the basis of all the movements that are done in the organization, and if there are no reliable statistics in the organization, planning will face problems and the available facilities will not be used properly. In other words, statistics is the most important tool for evaluating the performance of the past, present, planning for the future and one of the main factors of policy and management in any organization. Dark spots of explicit and unambiguous decision making can be lightened by statistics. On the other hand, planning based on accurate, correct and timely statistics is one of the keys to the success and progress of organizations. A manager can anticipate potential problems and find solutions to them by correct planning. Considering the role and importance of statistics in any system such as hospitals, the information in patients' files must be encrypted and coded to prepare reports and statistics.

Example of statistics unit affairs

  • Reviewing the statistics and report of the actions of the relevant unit monthly to present to the superior authority
  • Preparing hospital performance certificate
  • Preparing and collecting statistics of medical centers (hospital - clinic - clinic, etc.)
  • Preparing and collecting statistics of paraclinical centers (laboratory - clinic - clinic)
  • Preparing and collecting hospital activities and indicators (fixed bed - active bed - hospitalized and discharged patient, etc.) for managerial decisions
  • Preparing statistical tables and graphs
  • Preparing a seasonal performance summary and presenting it to the officials of the medical units
  • Responding to all statistical requests
  • Registering of information in Avab system monthly
  • Preparing and adjusting the necessary statistics for the health authorities of the center and the university

 

Disease Coding Unit:

The purpose of assigning a code number is to determine, identify and separate the studied subjects from each other, and refer to information and present different statistics. ICD book leads to coordination of executive methods of classification of diseases, treatment methods in different countries. Coding is an effective way to classify medical records based on diagnoses and treatments performed for patients, health care review, access to medical records quickly, research in the field of diseases and their treatment, access to health and vital statistics in a medical center.

Most importantly, with the correct use of coding systems, very extensive and valuable information will be obtained in various educational fields of medical and paramedical sciences.

The files are coded after entering the unit and before archiving. The hospital's internal policy for coding files is as follows:

  • Diagnoses, actions, and external causes of injuries as well as causes of death are coded according to instructions.
  • Coding policy is done internationally and according to official instructions and rules and with the utmost care by an experienced expert.
  • The books used for diagnoses are the ICD-10 three-volume book and the ICD-9CM two-volume book for actions.
  • During the coding, the files are re-examined and a qualitative review is performed to the extent of the coder's expertise.

Responsibilities of medical records coding expert:

  • Careful study of medical records of hospitalized, outpatient and emergency patients to determine the main diagnosis and type of action
  • Proper coding of disease diagnoses using the International Classification of Diseases (ICD-10) and compliance with relevant laws
  • Proper coding of medical and surgical procedures using the third volume of the American Disease Classification Book (ICD-9-CM) and compliance with relevant laws
  • Proper coding of external causes of accidents, including accidents, using the International Classification of Diseases (ICD-10) and compliance with relevant laws
  • Correct coding of the main cause and underlying causes of death using the International Classification of Diseases (ICD-10) and compliance with relevant laws
  • Identifying and reporting 20 major hospital diseases per month, season, 6 months and annually to the head of the medical records department
  • Guiding and cooperating with medical records interns in their field of work
  • Cooperating and communicating with the personnel of the medical records department and other departments of the hospital
  • Having a good mood and high public relations to communicate with the client and staff
  • Following up and performing things that are announced by the superior authority.