193 results.
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Spoliation of Medical Evidence
Author: Tomes, Jonathan P.
Source: Journal of AHIMA
Publication Date: October 2005
To avoid the improper destruction or alteration of records, HIM departments must follow a retention schedule, train personnel, and ensure that corrections leave original entries intact.
Although the legal concept known as spoliation of evidence has been a part of the American legal syste....
Physician Order Entry Goes Online: the Effect on Records and HIM Operations
Author: Curtis, Elizabeth
Source: Journal of AHIMA
Publication Date: October 2005
As CPOE turns from vision to reality, what impact is it having on HIM? And what impact is HIM having on it?
Installing an order entry system in a busy hospital environment can be a huge undertaking for administration, information systems, nursing, ancillary departments, and the medical s....
Update: Guidelines for Defining the Legal Health Record for Disclosure Purposes
Author: AHIMA e-HIM Work Group on the Legal Health Record
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: September 2005
This practice brief has been retired. It is made available for historical purposes only.
Sedona Principles: Best Practices Recommendations & Principles for Addressing Electronic Document Production
Author: Sedona Conference. Working Group on Best Practices for Electronic Documnet Retention & Production
Source: External web site
Publication Date: July 02, 2005
This is the post public-comment version of The Sedona Principles. The Working Group on Electronic Document Production was conceived to develop principles to guide organizational practices and legal doctrine.
Quest for Interoperable Electronic Health Records: a Guide to Legal Issues in Establishing Health Information Networks
Author: Rosati, Kristen; Lamar, Marilyn
Source: External web site
Publication Date: July 02, 2005
Leading from the Middle
Author: Hagland, Mark
Source: Journal of AHIMA
Publication Date: May 2005
With one eye on strategy and one on operations, HIM managers not only have the opportunity to facilitate change, they also have the responsibility.
Awareness of senior-level strategy combined with detailed organizational knowledge can give HIM managers keen eyesight. For Mary Staub, RHIA....
Prompt, the Alert, and the Legal Record: Documenting Clinical Decision Support Systems
Author: Rollins, Gina
Source: Journal of AHIMA
Publication Date: February 2005
As evidence-based medicine systems proliferate, organizations are grappling with the question of when—or whether—to document them in the legal record. So far, the prompts are many, but the answers are few.
A physician enters a medication order in a computerized physician orde....
Making Amendments Meaningful
Author: Amatayakul, Margret
Source: Journal of AHIMA
Publication Date: February 2005
Now that we’re well entrenched in compliance with the privacy rule and headed toward the electronic health record (EHR), the personal health record (PHR), and regional health information organizations (RHIOs), amendments may seem like a mundane topic. But, as this article explains, it is....
Copying and Pasting in the EHR-S: an HIM Perspective
Author: Helbig, Susan; Hammond, Kenric W.
Source: IFHRO Congress | AHIMA Convention
Publication Date: October 15, 2004
Introduction
The Department of Veteran Affairs (VA) has been implementing an electronic health record for several years. Beginning in 1997, VA Puget Sound Health Care System (VAPSHCS) began the systematic implementation of the first version of its computerized patient record system (CPRS....
Online Clinical Documentation in the Electronic Legal Medical Record
Author: Anderson, Ellen Miller
Source: AHIMA Convention
Publication Date: October 15, 2004
Abstract
The physical development of online clinical documentation is exploding in today's electronic medical record (EMR). It was predicted in 1998 that we would see major clinical documentation development in EMRs starting in 2000 and maturing by about 2005. If this development occurs....
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