Question

In the HIM profession what is abstracting?

(300 words) Typed, not written please, paragraphs only.

Answer 1

Health Information Management

Health Information Management( HIM) is the heart of a health care organization. It supplies much needed information to users such as physicians, staff nurses, allied health professionals, government health departments, health administrators and insurance companies. HIM plays a significant role in the maintenance of health information.

The Global Health Workforce Council has defined Health Information Management (HIM) as " the practice of acquiring, analysing, and protecting digital and paper based medical and health information vital to providing quality patient care and maintaining the daily operations management of health information and electronic health records".

Abstracting in HIM profession

Abstraction in HIM is the process in which a human manually searches through medical record to identify data required for a secondary use. Abstraction involves some direct matching of information found in the record to the data required, but also includes operations on the data such as categorizing, coding, transforming, interpreting, summarising and calculating.

Types of Data Abstraction

There are two types of clinical data abstraction; automated clinical data abstraction and manual clinical data abstraction. In the first type , the  computer or sever goes through the clinical content and using some combination of natural language processing ( NLP) or other technology, it identifies the important clinical data elements in a narrative passage. The second type is where a trained medical professional pulls out the various clinical data elements.

Proponents of clinical data abstraction argue that clinical data abstraction provides the best of both narrative with discrete data elements. Many doctors love to see and read the narrative.but discrete data elements is important in order to improve patient care.

The abstraction process results in a summary of information about a patient for a specific secondary data use. Clinical data abstraction remainder primary mode of data collection in clinical research, quality improvement, performance measurement, disease surveillance and other secondary data uses.