Rhonda B. Kiker
January 30, 2012
Health care information systems are a collection of data and information unique to health care. This information includes starting with an information structure that collects both administrative and clinical patient data, compiles the information, makes information available for up-to-date patient care all the way through the reimbursement process. These systems also aggregate data for reporting to measure outcomes. A description of different types of patient information and the key elements associated with the capture of health care data will be discussed. AMR
AMR is the abbreviation for the Administrative Medical Record. This deals with the non- patient care portion of records and keeps business flowing. This portion of the patient record includes information about scheduling, precertification, insurance eligibility determination, billing, and payment verification (Wager, Lee, & Glaser, 2009).
CMR is the abbreviation for the Clinical Medical Record. Common components of the clinical portion of the record include the identification sheet, problem list, medication record, history and physical, progress notes, consultation, physician orders, imaging and x-ray reports, laboratory reports, consents, operative reports, pathology reports, and discharge summary (Wager, Lee, & Glaser, 2009).
CMS is the abbreviation for Center for Medicare and Medicaid Services. CMS is charged with the oversight of the health care provided and reimbursement to Medicare and Medicaid recipients (Wager, Lee, & Glaser, 2009).
The center aggregates data from claim forms for analyzing national health care reimbursement, clinical, and population trends. The forms CMS-1500 and UB-04 collect the same data (Wager, Lee, & Glaser, 2009).
CMS-1500 is a form for billing that was developed by the National Uniform Claim Committee (NUCC). This committee was created by the American
References: HL7 Overview. (2010). Retrieved from http://www.interfaceware.com Redmond, M. (n.d.). UB92 Medical Claim forms-When and How to Use Them. Retrieved from http://www.ezinearticles.com Wager, K.A., Lee, F.W., & Glaser, J.P. (2009). Health care information systems: A practical approach for health care management, 2nd edition. San Francisco, CA: John Wiley & Sons, Inc