Capture and Structure of Health Information – Electronic vs Manual

Health care organizations continue to evolve in the use of electronic formats to capture, structure and facilitate the use of health information. In today’s healthcare environment organizations can range from entirely manual to entirely electronic, with many falling into a category of hybrid documentation which includes both. As a HIM professional you may have a role in ensuring that as an organization moves along continuum from paper to electronic that the documentation in the health record continues to support the diagnosis and reflect the patient’s progress, clinical finds and discharge status.