Putting the
HIM in IM
ASSIMILATING INTEGRATIVE MEDICINE INTO
CLINICAL DOCUMENTATION
As integrated medicine becomes more common, HIM professionals
have a unique opportunity to improve its documentation.
By Ruthann Russo, PhD, JD, MPH, MSAc, RHIT
WITH INTEGRATIVE MEDICINE (IM) services now offered by
80 percent of hospitals and healthcare systems, it’s safe to say
that integrative medicine is no longer a niche practice.
1 With
integrative medicine providers proliferating and the number of
services they offer increasing, it’s more important than ever to
ensure that everyone, including patients, can effectively use the
clinical documentation of IM providers. As a result, HIM professionals have significant opportunities in this area.
Because IM services are often provided in an outpatient clinic,
this subset of healthcare providers and their patients may fall
outside of the scope of work of the typical HIM professional. Increasingly, however, IM services are being provided in inpatient
settings as well. HIM professionals need to be aware of and assist these healthcare providers to understand the power of the
health record. The aim: to educate healthcare systems to standardize the documentation of integrative medicine practitioners in a way that is meaningful for the practitioner, the healthcare facility, and the patient.
This article offers an introduction to integrative medicine services and the licensed integrative medicine professions and explains integrative medicine patients’ opinions regarding their
health records. It also offers some suggestions for how HIM professionals can get started assimilating IM documentation into
the EHR and clinical documentation for coding.
Integrative Medicine Defined
“Integrative medicine” is the term used by most healthcare
systems to identify their use of complementary and alternative therapies within the structure of traditional medical care.
According to the Arizona Center for Integrative Medicine at the
University of Arizona: “Integrative medicine makes use of all
appropriate therapies, both conventional and alternative. Integrative medicine is a healing-oriented medicine that takes account of the individual as a unique and whole person, taking
into account body, mind, and spirit.”
2
For example, a patient seeking an integrative medicine ap-
