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Journal Q&A (7/02)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: July 02, 2002


Q: I have requested the immunization records from a patient’s former healthcare provider with the patient’s written permission. The former healthcare provider refuses to send the immunization records because the patient has a balance on the account. Is this legal?


A:....

Journal Q&A (7/02)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: July 02, 2002

Q: Where can I go to locate an article I read last year in the Journal of AHIMA?


A: You can find a wealth of HIM information in the AHIMA Library, the Association’s online body of knowledge. Selected Journal articles from 1996 to 2000 are stored there, as well as most articles....

Journal Q&A (7/02)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: July 02, 2002


Q: I work in a clinic setting. An attorney has requested copies of a patient’s entire record. The record includes reports dictated by one of the clinic physicians at a local hospital during the patient’s hospitalization. The attorney has the patient’s permission. Are we allowed....

Journal Q&A (11/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2000

Q: Is it acceptable to use "canned" reports in transcription?
A: To the extent that outlines or phrases common to one or more providers in assessments and procedures are routine, they can and should be used to assist providers in documenting thoroughly and efficiently. How....

Journal Q&A (11/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2000

Q: When a patient who was assaulted names her assailant, should the nurse or physician include the assailant's name in the medical record?
A: It is not uncommon for a healthcare provider to document in the record what the patient says when the information has some bearing on his or....

Journal Q&A (11/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2000

Q: Where can I find a benchmark for coding accuracy?
A: It's difficult to establish an industry standard for coding accuracy because accuracy is measured differently in every facility. Some facilities compute their accuracy rate by taking the number of correctly coded records and divi....

Journal Q&A (11/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2000

Q: Where can I find a medical record audit tool for physician practices?
A: Older versions of the HEDIS indicators contained a medical record audit tool that was used by many third-party payers with which physician groups contracted to provide medical care. If you have an old copy of HEDI....

Journal Q&A (11/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2000

Q: How long is an authorization to release information valid?
A: For the most part, federal law does not specify a length of time for which authorizations to disclose information are valid. In Confidentiality of Alcohol and Drug Abuse Patient Records (42 CFR, Chapter I, Part 2), the....

Journal Q&A (11/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2000

Q: My facility wants to adopt or modify an existing abbreviation list rather than develop its own. Where can I locate such a list?
A: If you work in a community where the physicians practice at more than one facility, it would be ideal if those facilities shared a common abbreviation....

Journal Q&A (10/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: October 02, 2000

Q: What is the retention period for billing records, such as explanations of benefits, charge slips, invoices, etc.?
A: Most states have established a retention period for medical records, but many have not addressed other type of records like billing documents. The Medicare program m....

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