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Evaluation of Inpatient Clinical Documentation Readiness for ICD-10-CM

Author: DeAlmeida, Dilhari R; Watzlaf, Valerie J.M.; Anania-Firouzan, Patti; Salguero, Otto; Rubinstein, Elaine; Abdelhak, Mervat N.; Parmanto, Bambang

Source: Perspectives in Health Information Management

Publication Date: January 2014


Abstract


This research study examined the gaps in documentation that occur when coding in ICD-10-CM. More than 4,000 diagnoses from all chapters were coded from 656 electronic documents obtained from a large integrated healthcare facility at the time the study was conducted (2012)....

Keeping Current in the Electronic Era: Data Age Transforming HIM’s Mandatory Workforce Competencies

Author: Sandefer, Ryan; DeAlmeida, Dilhari R; Dougherty, Michelle; Mancilla, Desla; Marc, David

Source: Journal of AHIMA

Publication Date: November 2014



Ponder this for a moment. From the beginning of recorded history to 2003, five exabytes (five billion gigabytes) of information was created by humans, according to recent IBM calculations. The rate at which that level of information is being created is increasing exponentially. In 2012, fi....