985 results.
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Dictation Best Practices for Quality Documentation
Author: Hurley, Brenda J.; Sims, Lea
Source: AHIMA Convention
Publication Date: October 31, 2006
Clinical documentation and health records play a vital role in every aspect of healthcare delivery and decision making, no matter what the setting. Complete and accurate documentation is also a central focus in current efforts to improve healthcare quality and patient safety as well as the ef....
EHR Case Study: How a Well-Managed Selection Process Led to a Successful IT Implementation
Author: Miller, Grace; Gabard, Carlotta
Source: Journal of AHIMA
Publication Date: October 2006
About five years ago, Integrated Health Associates’ (IHA) antiquated technology was hampering staff efforts to make the most of clinical and administrative data. To correct the situation, the 100-physician, multispecialty practice based in Ann Arbor, MI, embarked on an 18-month search t....
Key Points of the UB-04
Author: AHIMA Clinical Terminology and Classification Practice Council; Garrett, Gail S.; Johnson, Laurine; Johnson, Kathy M
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: October 2006
This practice brief has been retired. It is made available for historical purposes only.
New Electronic Discovery Civil Rule
Author: AHIMA e-HIM Work Group on e-Discovery
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: September 2006
This practice brief has been retired. It is made available for historical purposes only.
Who's on First?: the Interplay of HIPAA's "Required by Law" Exception and State Law
Author: Pritts, Joy
Source: Journal of AHIMA
Publication Date: September 2006
You receive a request for medical information from a third party. Generally HIPAA would prohibit releasing the information, but would allow disclosure when “required by law.” State law, however, generally requires disclosing the information, unless disclosure is prohibited by another law.
In the Winds of Change, Principles Provide a Steady Course
Author: Johns, Merida L.
Source: Journal of AHIMA
Publication Date: September 2006
HIM professionals have weathered dramatic structural, environmental, and technological winds of change due to several reasons, but the profession’s fundamental principles, remain unchanged even as they apply to each new method of practice. Our passions are the winds
that propel our vessel....
Best Practices in Electronic Health Records
Author: Amatayakul, Margret; Work, Mitch
Source: AHIMA
Publication Date: September 01, 2006
Facsimile Transmission of Health Information (2006 update)
Author: Blevins, Alicia; Davis, Nancy; Hjort, Beth M.; Lemery, Chrisann; Mangin, Wendy L; Mikels, Debra A; Nicholas, Cindy
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: August 2006
This practice brief has been retired. It is made available for historical purposes only.
Evolution of DRGs
Author: Boucher, Anne; Bowman, Sue E; Piselli, Caroline; Scichilone, Rita A
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: July 2006
This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.
Resource for Privacy and Security Programs: Version 5.0 of HIMSS CPRI Toolkit Expands to Include Privacy Topics
Author: Demster, Barbara
Source: Journal of AHIMA
Publication Date: July 2006
The breadth of available privacy and security literature can be daunting to even the most dedicated HIM professional. With the explosion of information on the Internet, access to authoritative-as well as questionable-resources is easy and instantaneous. The problem of access has morphed into o....
Essential People Skills for EHR Implementation Success
Author: Fenton, Susan H.; Giannangelo, Kathy; Stanfill, Mary H
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: June 2006
This practice brief has been retired. It is made available for historical purposes only.
Tips for Successful Teamwork
Author: Burrington-Brown, Jill
Source: Journal of AHIMA
Publication Date: June 2006
AHIMA’s e-HIM work groups have had great success in bringing together groups of HIM professionals to explore and create guidance on cutting-edge e-HIM practices and technology. These groups also teach us lessons about the factors of successful teamwork that we can apply to our own work si....
Getting off to a Good Start: Tips from the Launch of Two HIM Systems
Author: Harker, Kathy
Source: Journal of AHIMA
Publication Date: June 2006
Northwest Health System followed a smooth launch of a coding product with something a little more ambitious—a beta version of a document management system.
In April 2005 Northwest Health System in Springdale, AR, implemented Web-based coding to boost productivity. The system....
What's Wrong with RFPs?: Best Practices and New Ideas for Choosing IT Vendors
Author: Bedrosian, Dan; McCoy, Michael J.
Source: Journal of AHIMA
Publication Date: May 2006
The RFP is a time-honored rite of vendor selection. But it has its drawbacks, and alternative strategies can offer advantages.
In the fast-changing world of health IT, vendor selection would seem to be a rare well-established procedure. But the traditional selection process has its pitfa....
Hybrid Records in a Hospice Setting
Author: Barbera, Linda
Source: Journal of AHIMA
Publication Date: May 2006
The hospice setting is no stranger to the challenges of transitioning from paper to electronic documentation. Ensuring that hybrid medical records provide complete and accurate documentation is a significant issue, particularly for reimbursement processes. In order for the documentation to prov....
Time for a HIPAA Tune-Up?: Penalties Now in Effect for Noncompliance
Author: Quinsey, Carol Ann
Source: Journal of AHIMA
Publication Date: May 2006
On February 16, 2006, the Department of Health and Human Services published the final rule adopting policies enforcing the HIPAA provisions. The rule imposes civil monetary penalties on covered entities that violate any of the HIPAA administrative simplification rules, not just the privacy rul....
Purchasing Strategies for EHR Systems
Author: McLendon, Kelly
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: May 2006
This practice brief has been retired. It is made available for historical purposes only.
Model Privacy Policies and Procedures for Health Information Exchange
Author: Connecting for Health
Source: External - used with permission
Publication Date: April 06, 2006
Using HL7 Standards to Evaluate an EHR
Author: Quinsey, Carol Ann
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: April 2006
This practice brief has been retired. It is made available for historical purposes only.
Word Power: a Glossary of Software Licensing Terms
Author: AHIMA
Source: Journal of AHIMA
Publication Date: April 2006
This Software license agreement is entered into by and between Sample Software, Inc, a Delaware corporation with principal offices located at 100 Maple Lane, Chicago, Illinois 60601 ("Sample") and _________________, a corporation with principal offices located at ________________ ("Licensee") a....
Running out of Room for Data: HIPAA Requires Healthcare Organizations to Re-assess Data Storage
Author: Brick, Frank
Source: Journal of AHIMA
Publication Date: April 2006
Computer systems are feeling the effects of HIPAA. That's because the act's privacy and security rules require covered entities to securely store and manage more data than ever before. The latest computers to feel the effect are those in small covered entities, where the security rule takes ef....
Benchmarking RCM: Best Practices to Enhance the HIM Role in Revenue Cycle Management
Author: Amatayakul, Margret
Source: Journal of AHIMA
Publication Date: March 2006
A new study identifies the HIM best practices that influence revenue cycle management.
Revenue cycle management (RCM) has been defined as "all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue."1 RCM in hospitals is....
Using the SSN as a Patient Identifier
Author: AHIMA e-HIM Work Group on Regional Health Information Organizations (RHIOs)
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: March 2006
This practice brief has been retired. It is made available for historical purposes only.
Authentication in EHRs
Author: Green-Shook, Sheila; Quinsey, Carol Ann
Source: Journal of AHIMA
Publication Date: March 2006
Group Health Cooperative (GHC) is an integrated healthcare system with 29 primary care clinics, four specialty centers, two hospitals, 10,000 employees, and 700 physicians. GHC serves 540,000 patients across Washington state and northern Idaho.
In 2003 GHC began implementing an elec....
Guidelines for Developing a Data Dictionary
Author: AHIMA e-HIM Work Group on EHR Data Content
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: February 2006
This practice brief has been retired. It is made available for historical purposes only.
Data Mapping
Author: McBride, Susan; Gilder, Richard; Davis, Robert; Fenton, Susan H.
Source: Journal of AHIMA
Publication Date: February 2006
Exchanging health data electronically requires some cartography. HIM professionals not involved with data mapping now will be soon.
One essential component of health IT interoperability, and the improved care and efficiency it offers, is data mapping. Data mapping....
Writing the RHIO Fine Print: Model Policies and Specifications Speed Data Exchange Start-Ups
Author: Stein, Todd
Source: Journal of AHIMA
Publication Date: February 2006
Fledgling RHIOs get a head start with new model policies and technical guidelines from Connecting for Health.
When Chuck Fitch first began to promote a regional health information network for Memphis’s far-flung hospitals, medical centers, county clinics, and physician groups thre....
Surveying the RHIO Landscape: A Description of Current RHIO Models, with a Focus on Patient Identification
Author: E-HIM Work Group on Patient Identification in RHIOs
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: January 2006
This practice brief has been retired. It is made available for historical purposes only.
Health Information Form for Children
Author: AHIMA
Source: AHIMA sample form
Publication Date: 2006
Health Information Form for Adults
Author: AHIMA
Source: AHIMA
Publication Date: 2006
Maintaining a Legally Sound Health Record: Paper and Electronic
Author: E-HIM Work Group on Maintaining the Legal EHR
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: November 2005
This practice brief has been retired. It is made available for historical purposes only.
Practice Toolkit: EHR Implementation
Author: Hall, Terri
Source: Journal of AHIMA
Publication Date: November 2005
The Billings Area Indian Health Service (IHS) began implementing an electronic health record (EHR) about three years ago, beginning with the Crow Acute Care Hospital and its Wind River outpatient clinics. This article outlines the steps the organization took to reach “go live.”
Classification of Coagulopathy
Author: Grebner, Leah A.; Stanfill, Mary H
Source: Journal of AHIMA - Coding Notes
Publication Date: November 2005
The term coagulopathy can be confusing for coding professionals because it may refer to a myriad of conditions that are classified differently in ICD-9-CM. Take for example a patient who has bleeding somewhere (e.g., hematuria or epistaxis). The physician lists “coumadin coagulopathy&rd....
Emergency Department—Facility E/M Coding Best Practices
Author: Hirschl, Nancy
Source: AHIMA Convention
Publication Date: October 21, 2005
Introduction
Revenue management and coding compliance for emergency department (ED) services have become increasingly difficult to handle. Factors contributing to this include lack of mandated evaluation and management (E/M) coding guidelines, EMTALA regulations, demands for cash....
Documentation Improvement Initiative at Maimonides Medical Center, Brooklyn, NY
Author: Rivera, Madeline; Zusman, Irina; Kogan, Susanna; Sichalov, Nadia; Spector, Michelle
Source: AHIMA Convention
Publication Date: October 21, 2005
Summary
Maimonides Medical Center (MMC) in Brooklyn, NY, implemented a successful documentation improvement program in 2001. Under the auspices of the Case Management Department, documentation specialists, who are credentialed HIM professionals (RHIA, CCS), perform concurrent and....
Surgical Services Revenue Enhancement/Charge Capture Team: A Case Study Using Six Sigma Principles
Author: Whitaker, Lisa Lowe
Source: AHIMA Convention
Publication Date: October 21, 2005
Introduction
Six Sigma is the new kid on the block for performance improvement in healthcare; however, it is not new to the manufacturing world. Companies such as Motorola, Toyota, and GE have used Six Sigma since the 1980s to improve their business processes. Six Sigma is defined as “an....
Revenue Integrity and Coding Compliance: the Sharp Experience
Author: Hirschl, Nancy; Belton, Paul
Source: AHIMA Convention
Publication Date: October 21, 2005
Introduction
Traditionally, compliance programs have focused on the seven required elements from auditing and monitoring to hotline investigations. Most of these elements have become routine and solidified into every compliance program. In truth, seasoned compliance officers often....
Implementation of Documentation Enhancement Program at the Ohio State University Health System
Author: Osborn, Carol E.; Curtis, Elizabeth
Source: AHIMA Convention
Publication Date: October 21, 2005
Background
Of late, there has been much interest in the relationship between medical record documentation, coding, and the organization’s case-mix index (CMI). Many organizations have implemented documentation improvement programs with the goal of obtaining more specificity in codin....
Legal Process and Electronic Health Records
Author: AHIMA e-HIM Work Group on the Legal Health Record
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: October 2005
The custodian of an electronic health record (EHR) has the same concerns as the custodian of a paper health record when the record becomes involved in the legal process. Most often this occurs in some form of lawsuit in which a party seeks to discover and introduce evidence from the record. The....
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....
Coding Ethically
Author: Bronnert, June
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2005
With the many reimbursement issues and regulatory requirements surrounding coding, it is sometimes necessary for coders to refamiliarize themselves with what it means to code ethically. AHIMA’s Coding Policy and Strategy Committee developed the Standards of Ethical Coding, which were app....
Checklist for Assembling Health Information After a Disaster
Author: AHIMA Professional Practice Team
Source: AHIMA
Publication Date: September 19, 2005
September 19, 2005
The following information is provided by the American Health Information Management Association in the aftermath of Hurricane Katrina.
When people are displaced by disasters, it can be difficult to begin or resume medical care without healthcare informatio....
Forms Management Process: Keeping Pace with EHR Development
Author: Westhafer, Kathy J
Source: Journal of AHIMA
Publication Date: September 2005
Have you given any thought to how your medical record committee and forms management process need to transition with electronic health record (EHR) development? At the Christiana Care Health System, we have. Here’s our evolving story.
Christiana Care is a two-hospital health 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.
Best Practices in Revenue Cycle Management
Author: Amatayakul, Margret; Work, Mitch
Source: AHIMA
Publication Date: August 01, 2005
Role of the Personal Health Record in the EHR - Retired
Author: AHIMA e-HIM Personal Health Record Work Group
Source: AHIMA practice brief
Publication Date: July 2005
This practice brief has been updated. See the latest version here. This version 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.
ABC Medical Center Return Of Invalid Authorization for Release of Information
Author: Brandt, Mary D.
Source: AHIMA sample form
Publication Date: June 14, 2005
Sample form for sending to patient when critical information missing from the patient-submitted authorization form for release of information.
Checklist For Disclosures To Law Enforcement Officers
Author: Brandt, Mary D.
Source: AHIMA sample form
Publication Date: June 14, 2005
Law Enforcement Request For Records
Author: Brandt, Mary D.
Source: AHIMA sample form
Publication Date: June 14, 2005
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