HIM Director

Regardless of where the clinical documentation function is housed in your organization, the Health Information Management (HIM) department is a key player in any clinical documentation quality program. It is the HIM coders who translate the physicians’ documentation into the coded data that your hospital relies on for reimbursement, quality ratings, and planning and research.

It is essential for the HIM department to have a positive and productive relationship with the physicians on your medical staff. Most physicians will interact at some point with members of the HIM department responding to questions about their clinical documentation that were not obtained on the units. The physician is the customer of the HIM department. Just like with any customer relationship, you are more likely to obtain a timely and optimal response if you have a good relationship with the customer, who in this case happens to be the physician.

As a way to assess the HIM-physician relationship, Volume 2 contains an assessment survey to be completed by all HIM managers and if possible, some sampling of members of the medical staff. The survey for the HIM management team asks questions about the respondents’

• Knowledge of physicians as a group
• Knowledge of each physician/individual physicians
• Formal communications
• Informal communications
• Hospital’s “culture clarity”
• Physician support for hospital activities
• “Serving your physicians”
• Level of respect (that physicians have for the HIM staff)

The book addresses the assessment process and steps you can take to identify specific issues and make improvements in the HIM-medical staff relationship.