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Publication Date: October 2013

Editor's note: This practice brief supersedes the October 2011 practice brief "Sanction Guidelines for Privacy and Security Violations."

The HIPAA Breach Notification Rule requires healthcare providers, health plans, and other HIPAA covered entities (CEs) to notify individuals whe....

Guidelines for a Compliant Business Associate Agreement - Retired

Author: AHIMA

Publication Date: November 2013

This 2013 practice brief version has been retired and is retained here for historical purposes. Read the 2016 updated version of this Practice Brief here.

The Privacy Rule portion of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 defines a "business....

Reconciling and Managing EMPIs (2010 update)

Author: AHIMA

Publication Date: April 2010

This practice brief has been retired. It is made available for historical purposes only.

Authorization Requirements for the Disclosure of Protected Health Information. Appendix A: Sample Authorization Form

Author: AHIMA

Publication Date: November 2013

ICD-9-CM Coding Guidance for LTC Facilities - Retired

Author: AHIMA

Publication Date: October 2010

Diagnostic coding plays several important roles in every healthcare setting, including long-term care (LTC) nursing facilities. LTC facilities assign ICD-9-CM codes to capture a resident's clinical conditions.

ICD-9-CM facilitates the collection and organization of healthcare stat....

Verbal/Telephone Order Authentication and Time Frames (2012 update)

Author: AHIMA

Publication Date: August 2012

Editor’s note: This update replaces the June 2010 practice brief “Verbal/Telephone Order Authentication and Time Frames.”

It is important for a healthcare facility to review and understand all applicable federal and state laws and accreditation standards when de....

EHR Adoption in LTC and the HIM Value. Appendix B: Vendor Questionnaire for EHR System Selection

Author: AHIMA

Publication Date: January 2011

Evaluation Criteria
Vendor A
Vendor B
Vendor C
Name and Address of Home Office Phone Number Sales/Contact Representative....

Role-based Model for ICD-10 Implementation: Health Plans

Author: AHIMA

Source: AHIMA

Publication Date: November 18, 2009

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Declaration of complete medical record (retiring incomplete records)

Author: AHIMA

Source: AHIMA sample form

Publication Date: October 17, 2002

Sample Telecommuting Confidentiality Policy

Author: AHIMA

Source: AHIMA sample form

Publication Date: July 02, 2002

CSA ICD-10-CM/PCS Resource Guide - Retired
(The content in this toolkit has been retired. It is made available for historical purposes only.)

Author: AHIMA

Source: AHIMA toolkit

Publication Date: April 02, 2013

Consumer-Facing Health Information Practices - Retired

Author: AHIMA

Publication Date: September 2012

Increased adoption and use of health information technology by healthcare providers has made greater consumer access to health information possible, as well as increased general engagement in health maintenance and care. The opportunities for improving quality and efficiency afforded by this ne....

Sample Consent for Clinical Photography, Videotaping, Audiotaping, and Other Multimedia Imaging of Patients

Author: AHIMA

Source: Journal of AHIMA

Publication Date: April 2010

This sample policy and procedure is not intended for adoption as a substitute for a customized internal organizational specific policy and procedure. This policy is not inclusive of specific state or organizational requirements and should not be used without editing for specific information. An....

Fundamentals of the Legal Health Record and Designated Record Set

Author: AHIMA

Publication Date: February 2011

Throughout this brief, sentences marked with the † symbol indicate AHIMA best practices in health information management. These practices are collected in the new AHIMA Compendium, offering health information management professionals "just in time" guidance as they research and address p....

Statement Accompanying Disclosures

Author: AHIMA

Source: AHIMA sample form

Publication Date: January 02, 1997

Quality Data and Documentation for EHRs in Physician Practice

Author: AHIMA

Publication Date: August 2008

This practice brief has been retired. It is made available for historical purposes only.

Identifying Issues in Facility and Provider Mergers and Acquisitions (2012 update)

Author: AHIMA

Publication Date: February 2012

Editor's note: This practice brief supplants the November 1996 brief "Managing Health Information in Facility Mergers and Acquisitions."

Healthcare's rapidly changing environment has prompted an increase in mergers and acquisitions as facilities and providers strive to s....

Patient Access and Amendment to Health Records. Appendix B: Sample Patient Request for Amendment Form (2011 update)

Author: AHIMA

Publication Date: January 2011

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Retention and Destruction of Health Information (2011 update)

Author: AHIMA

Publication Date: August 2011

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Automated Coding Workflow and CAC Practice Guidance (2010)

Author: AHIMA

Publication Date: July 2010

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Climbing Higher: Bridging the Gap to Advanced Degrees in HIM

Author: AHIMA

Publication Date: August 2012

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Sample Request for an Accounting of Disclosures

Author: AHIMA

Source: AHIMA sample form

Publication Date: November 02, 2001

Role-based Model for ICD-10 Implementation: Outpatient Coders

Author: AHIMA

Source: AHIMA

Publication Date: November 18, 2009

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Patient Access and Amendment to Health Records. Appendix A: Sample Amendment Policy and Procedure (2011 update)

Author: AHIMA

Publication Date: January 2011

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

HIM Functions in Healthcare Quality and Patient Safety. Appendix C: HIM’s Role in Data Capture, Validation, and Maintenance

Author: AHIMA

Publication Date: August 2011

A critical component of AHIMA's draft HIM Core Model, a robust description of the functions and opportunities open to current and future HIM professionals, is capture and maintenance of health data.1 HIM professionals are encouraged to assume a leadership role in outlining how data are captured....

Sample Staff Competency List (Disaster Planning)

Author: AHIMA

Source: AHIMA sample form

Publication Date: June 02, 2003

Contractor/Vendor Nondisclosure Agreement

Author: AHIMA

Source: AHIMA sample form

Publication Date: January 02, 1997

ICD-9-CM Coding Guidance for LTC Facilities. Appendix C: Regulatory Guidance for Reporting Diagnoses Related to Reimbursement

Author: AHIMA

Publication Date: October 2010

In August 2000, the HIPAA Transaction and Code Sets required the use of the ICD-9-CM code set. Subpart J, section §162.1002 Medical data code sets, states the adoption of the following code sets as standard medical data code sets:
ICD-9-CM, volumes 1 and 2 (including the "ICD-9-CM Official....

Building an Evidence Base for High-Quality HIM

Author: AHIMA

Publication Date: May 2008

This practice brief has been retired. It is made available for historical purposes only.

EHRs as the Business and Legal Records of Healthcare Organizations. Appendix A: Issues in Electronic Health Record Management (2010 update)

Author: AHIMA

Publication Date: November 2010

Electronic health record management (EHRM) is the process by which electronic (e.g., digital) health records are created or received and preserved for legal or business purposes. EHRM requires decision making throughout the EHR’s life cycle-through the processing, distribution, maintenanc....

Using CDI Programs to Improve Acute Care Clinical Documentation in Preparation for ICD-10-CM/PCS (2014 update)

Author: AHIMA

Publication Date: December 2014

Editor's note: This practice brief has been updated. See the latest version here.

Termination Nondisclosure Agreement for Employees/Students/Volunteers

Author: AHIMA

Source: AHIMA sample form

Publication Date: June 02, 2003

[Name of healthcare provider] has a legal and ethical responsibility to safeguard the privacy of all patients and protect the confidentiality of their health information. In the course of my employment/assignment at [name of healthcare provider], I may have come into possession of or overheard....

Sample Consent for Photography/Videotaping (for Media or Educational Purposes)

Author: AHIMA

Source: AHIMA sample form

Publication Date: June 02, 2001

Patient’s Name:
Identification Number:

I hereby give my consent to have photographs, videotaped images, or other images made of myself or my family member and/or consent to interviews with a member of the news media or....

Procedures for Planned and Unplanned Downtime

Author: AHIMA

Source: AHIMA sample form

Publication Date: July 02, 2002

Putting the ICD-10-CM/PCS GEMs into Practice (2013 update)

Author: AHIMA

Publication Date: May 2013

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Disaster Planning for Health Information (2010 Update)

Author: AHIMA

Publication Date: December 2010

The content in this practice brief has been retired. This version is made available for historical purposes only. More recent information is available here.

Sample Disclosure Restriction Form

Author: AHIMA

Source: AHIMA sample form

Publication Date: October 02, 2001

Patient Access and Amendment to Health Records (2013 update)

Author: AHIMA

Publication Date: October 2013

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

10 Security Domains (2011 update)

Author: AHIMA

Publication Date: July 2011

This is the original web version of the practice brief, published in the May 2012 Journal of AHIMA. This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Understanding Governmental Audits

Author: AHIMA

Publication Date: July 2011

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Problem List Guidance in the EHR. Appendix A: Sample Policy and Procedure Template

Author: AHIMA

Publication Date: September 2011

There is no one-size-fits-all approach to developing and using problem lists, but rather multiple approaches to be considered. This sample policy is intended to provide guidance for organizations developing problem list policy. Organizations must take national standards and organizational opera....

HIPAA Privacy and Security Training (2010 update)

Author: AHIMA

Publication Date: November 2010

This practice brief has been retired. It is made available for historical purposes only.

Clinical Documentation Improvement Toolkit (2014)

Author: AHIMA

Source: AHIMA toolkit

Publication Date: January 2014

The content in this toolkit has been updated. More recent information is available here.

Clinical Documentation Improvement Toolkit (2010)

Author: AHIMA

Source: AHIMA toolkit

Publication Date: June 21, 2010

The content in this toolkit has been updated. More recent information is available here.

Electronic Documentation Templates Support ICD-10-CM/PCS Implementation. Appendix A: Electronic Note Title and Template Policy Considerations

Author: AHIMA

Publication Date: October 2012

This model policy recommends important legal and compliance considerations for healthcare organizations when establishing electronic note titles, templates, and/or prompts.

PURPOSE: To provide guidance on the development and maintenance of electronic note titles, templates, and p....

Employee/Student/Volunteer Nondisclosure Acknowledgment

Author: AHIMA

Source: AHIMA sample form

Publication Date: January 02, 1997

Understanding the HIE Landscape

Author: AHIMA

Publication Date: September 2010

The health information exchange (HIE) landscape has changed dramatically over the past five years. More HIEs are available to organizations and providers than ever before. Industry initiatives leveraging technological advances and the call for all Americans to have an electronic health record b....

Internet Resources for Accurate Coding and Reimbursement Practices (2010 update)

Author: AHIMA