RESUMO
It is time to make the case for health information management (HIM) to be included in science, technology, engineering, and math (STEM) education. A careful review of the HIM competencies approved by the American Health Information Management Association (AHIMA) illustrates the role of HIM professionals in informatics, data analytics, and data use. More precisely, the competency subdomains clearly align with content in the STEM disciplines of science, math, and technology, and the individual competencies or tasks in each subdomain solidify the assertion that HIM should be considered part of the STEM disciplines. Evaluation of AHIMA membership data showed that, at the education and work setting levels, AHIMA members are employed in many areas that are common to both HIM and STEM.
Assuntos
Gestão da Informação em Saúde , Informática MédicaRESUMO
This research study examined the gaps in documentation that occur when coding in ICD-10-CM. More than 4,000 diagnoses from all chapters were coded from 656 electronic documents obtained from a large integrated healthcare facility at the time the study was conducted (2012). After the documents were coded, areas for documentation improvement were identified for chapters that resulted in deficiencies in documentation, and a quick reference guide was developed. The overall absent documentation percentage was 15.4 percent. The 10 chapters with the highest percentage of absent documentation were chapter 7 (Diseases of Eye and Adnexa), with 67.65 percent (p < .001); chapter 8 (Diseases of Ear and Mastoid Process), with 63.64 percent (p < .001); chapter 13 (Diseases of the Musculoskeletal System and Connective Tissue), with 46.05 percent (p < .001); chapter 14 (Diseases of the Genitourinary System), with 40.29 percent (p < .001); chapter 10 (Diseases of Respiratory System), with 35.52 percent (p < .001); chapter 1 (Infectious and Parasitic Diseases), with 32.88 percent (p < .001); chapter 12 (Diseases of the Skin and Subcutaneous Tissue), with 32.35 percent (p < .001); chapter 2 (Neoplasms), with 25.45 percent (p < .001); chapter 4 (Endocrine, Nutritional and Metabolic Diseases), with 14.58 percent (p < .001); and chapter 17 (Congenital Malformations, Deformations, and Chromosomal Abnormalities), with 12.50 percent. We addressed the deficient areas in the quick reference guide developed for clinicians and technology vendors. Having complete and accurate documentation would benefit both the clinician and the patient in providing the highest quality of care.