Health Documentation: Internal Information and Processes
Types of Internal Information
Internal information includes data contained within documents generated by a health center during its operations. We can distinguish two main types:
- Information on Logistics: This includes data in documents discussing the general operation of the facility (warehouse, accounting, etc.). These documents are managed by the Administrative Archives.
- Information Relating to Patient Care: This includes data in clinical and administrative documents related to direct patient care (clinical notes, analyses, discharge reports), which are managed by the Clinical Documentation Unit.
Clinical Documentation Unit Defined
The Clinical Documentation Unit is the information subsystem of the health system responsible for processing the information contained in medical records.
Powers of the Clinical Documentation Unit
- Design and standardization of documents.
- Continuous improvement of information processing.
- Establishment of quality assurance measures.
The Document Chain
The document chain is the set of operations a document undergoes when entering the Clinical Documentation Unit.
Phases of the Document Chain
- Input Information (Input): This involves the collection of the document, allowing for bottom-up processing and feeding of information.
- Documentary Information Processing: This occurs in two phases:
- Intellectual Treatment: Description, classification, and coding of documents.
- Material Processing: Archiving, storage, etc.
- Output of Information (Output): This includes:
- Recovery of information.
- Dissemination of information: reports, loans, consultation, and reproduction.
Competency Units in Health Documentation Technician
- Organize and manage documentation files and medical records.
- Participate in the process of information processing and clinical documentation.
- Identify, extract, and encode clinical and non-clinical health documentation.
- Validate and use data in the MDS or other statistical tools, epidemiological data, and quality control.
Producers of the Documentary Chain
These are individuals who generate or originate the information contained in a document. This includes all professionals who write in the medical history: doctors, nurses, professional services (radiology, laboratory, pathology), social services professionals, and other professionals, as well as patients themselves and their families.
Information Managers
These individuals perform the intellectual processing of information (identification, data extraction, and coding of clinical and non-clinical data) and material treatment (primarily the physical archiving of documentation).
Intellectual Processing vs. Material Treatment
- Material Treatment: Maintaining the information contained in or supported by the medical history (archiving of documentation).
- Intellectual Treatment: Identifying, extracting, and encoding data related to care and non-care assistance.