Author: AHIMA

Source: AHIMA practice brief

Publication Date: November 2010

Editor's note: This update replaces the July-August 2005 practice brief "The Role of the Personal Health Record in the EHR."


Health information technology will be integral to the US transformation to a safer, more efficient, consumer-driven healthcare system, and the personal heal....

Author: AHIMA

Source: AHIMA

Publication Date: November 18, 2009

h1, h2 { color:#f2b006; margin:0; } h1 { font-size:2.5em; font-weight:bold; line-height:1em; margin-bottom:.25em; } h2 { font-size:1.5em; font-weight:normal; line-height:1.1em; margin:1em 0 .2em 0; } h3 { text-transform:uppercase; font-weight:bold; ....

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: October 2013

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: July 2013

A strong clinical documentation improvement (CDI) program begins with the proper recruitment, careful selection, and adequate orientation of CDI specialists. The purpose of a CDI program is to initiate concurrent and retrospective reviews of health records for conflicting, incomplete, or nonspe....

Author: AHIMA

Source: AHIMA practice brief

Publication Date: November 2010

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

Author: AHIMA

Source: AHIMA sample form

Publication Date: January 02, 1997

Author: AHIMA

Source: AHIMA sample form

Publication Date: December 15, 2010

Author: AHIMA

Source: AHIMA practice brief

Publication Date: July 2010

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

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: August 2011

A solid foundation is key to any organization's structure. The same is true for HIM. Information stewardship and data governance practices provide cohesive policies, processes, and decision rights and responsibilities for effective health information management and maintenance.1

The....

Author: AHIMA

Source: AHIMA sample form

Publication Date: May 02, 2000

Author: AHIMA

Source: AHIMA sample form

Publication Date: November 13, 2002

Sample notice describing how information about a patient may be used and disclosed and how the patient can get access to the information.

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: April 2013

The Occupational Safety and Health Administration (OSHA) defines an “occupational medical record” as an occupation-related, chronological, cumulative record, regardless of the form or process by which it is maintained (i.e., paper document, microfiche, microfilm, or automatic data processing me....

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: January 2013

The health information exchange (HIE) landscape has changed dramatically since HIE and the Nationwide Health Information Network (NwHIN) was first conceptualized in 2001. The National Committee on Vital and Health Statistics (NCVHS) published recommendations in 2001 on nationwide electronic hea....

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: October 2013

The EHR has changed certain concepts and terms related to signatures. In the past, HIM professionals identified the act of signing an entry as authentication. However, this definition has evolved.


In EHRs, authentication is the security process of verifying a user’s identity....

Author: AHIMA

Source: AHIMA practice brief

Publication Date: February 2012

Editor's note: This update replaces the November–December 2008 practice brief "Management Practices for the Release of Information."

Exchange of health information is an essential function for the provision of high-quality, cost-effective, and safe healthcare. The health information....

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: February 2012

Purpose:
To ensure all health information-related tasks are addressed in the process of setting up a new clinic.
Departments Needed: Contracting, Marketing, IS, HIM, Patient Management Systems, EMR Team, Clinic Management, Billing/Coding Questions to Answer:
1. What is the legal name....

Author: AHIMA

Source: AHIMA sample form

Publication Date: January 02, 1997

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: October 2010

On January 16, 2009, the Department of Health and Human Services released final rules to adopt X12 Version 5010 claim form of HIPAA's Transaction and Code Set Standard and ICD-10-CM and ICD-10-PCS. Healthcare organization must implement version 5010 by January 1, 2012. The implementation deadli....

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: January 2011

In the early 1900s the American College of Surgeons' Hospital Standardization Program provided guidance on how to organize data in medical records for research. Currently many disciplines use medical records for a variety of purposes. Since the early days, HIM professionals have guarded the int....

Author: AHIMA

Source: AHIMA practice brief

Publication Date: June 2010

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

Author: AHIMA

Source: AHIMA sample form

Publication Date: February 02, 2002

Author: AHIMA

Source: AHIMA practice brief

Publication Date: August 2011

Editor's note: This update supplants the November 2003, March 1999, and September 1996 practice briefs "Protecting Patient Information after a Facility Closure."



Today's healthcare environment fosters competitiveness and complex business relationships. These environment....

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: January 2011

Electronic health record systems offer many opportunities for long-term care (LTC) facilities and their patients, and momentum is building for their widespread adoption across care settings.


Although some federal health IT initiatives benefit long-term care, LTC facilities are not....

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: January 2011

Hospitals developed compliance programs in response to a 1991 federal Sentencing Commission policy mandating penalties for organizations convicted of federal crimes. These federal crimes include fraud and abuse of the Medicare and Medicaid programs. If an organization's compliance program inclu....

Author: AHIMA

Source: AHIMA sample form

Publication Date: January 02, 2002

Author: AHIMA

Source: AHIMA

Publication Date: November 18, 2009

h1, h2 { color:#f2b006; margin:0; } h1 { font-size:2.5em; font-weight:bold; line-height:1em; margin-bottom:.25em; } h2 { font-size:1.5em; font-weight:normal; line-height:1.1em; margin:1em 0 .2em 0; } h3 { text-transform:uppercase; font-weight:bold; ....

Author: AHIMA

Source: AHIMA practice brief

Publication Date: May 2010

The content in this practice brief has been updated. See updated information here.

Author: AHIMA

Source: AHIMA practice brief

Publication Date: September 2013

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only. This update supersedes the January 2010 practice brief "Understanding Publicly Available Healthcare Data."



Healthcare organizations increasingly ar....

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: January 2011

HIM professionals working in LTC facilities using EHRs are responsible for the following areas and tasks:
Supervisory/Management
Develop and maintain policy and procedures and job descriptions for the health information department
Manage human resource functions for the departme....

Author: AHIMA

Source: AHIMA sample form

Publication Date: April 02, 2003

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: October 2008

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

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: September 2010

On May 13, 2010, the Office of the National Coordinator for Health Information Technology awarded approximately $550 million in grants to State Health Information Exchange Cooperative Agreement Programs and State Designated Entities as part of the American Recovery and Reinvestment Act of 2009.....

Author: AHIMA

Source: AHIMA practice brief

Publication Date: October 2013

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

Author: AHIMA

Source: AHIMA sample form

Publication Date: February 02, 2002

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: March 2010

Myocardial Infarction

The ICD-9-CM codes for myocardial infarction (MI) classify the diagnosis according to whether it is the patient’s initial or subsequent visit for treatment of a particular MI. This information is not contained in the ICD-10-CM codes.

To determine the correc....

Author: AHIMA

Source: AHIMA toolkit

Publication Date: May 02, 2013

This toolkit provides guidance for developing policies and procedures, establishing an educational program and managing record requests, denials, and appeals. It highlights some of the government entities and programs that focus on medical record audits.

Author: AHIMA

Source: AHIMA toolkit

Publication Date: June 06, 2012

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: August 2011

Editor's note: this practice brief supplants the January 2005 practice brief "The HIM Role in Patient Safety and Quality of Care."


Achieving high quality, cost-efficient healthcare requires collaboration among all healthcare professionals and stakeholders. Currently the quality of....

Author: AHIMA

Source: AHIMA sample form

Publication Date: November 02, 2003

Author: AHIMA

Source: AHIMA practice brief

Publication Date: September 2010

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

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: November 2009

Addendum: new documentation added to an original entry. Addendums should be timely and bear the current date and reason for the additional information being added to the health record.

Alternate signature: see proxy signature.

Amendment: documentation meant to clarify health....

Author: AHIMA

Source: AHIMA toolkit

Publication Date: August 24, 2009

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: June 2011

The federal government has passed multiple laws restricting or prohibiting SSN use in the following areas:
Financial SSN Restrictions

1999

Title V of the Gramm-Leach-Bliley Act imposed privacy and security obligations on financial institutions with respect to customers....

Author: AHIMA

Source: AHIMA toolkit

Publication Date: April 2017

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: June 2011

1935

The Social Security Act (PL 74-271) is enacted. It did not expressly mention the use of SSNs, but it authorized the creation of some type of record-keeping scheme.

1936-1937

Approximately 30 million applications for SSNs were processed between November 1936....

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: November 2012

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: March 2010

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

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: November 2010

Editor's note: This checklist combines and updates the October 2004 practice brief appendix "The Strategic Importance of Electronic Health Records Management: Checklist for Transition to the EHR" and the June 2005 practice brief "A Checklist for Assessing HIM Department Readiness and Planning f....

Author: AHIMA

Source: AHIMA practice brief

Publication Date: December 2010

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

Author: Adragna, Lisa

Source: Journal of AHIMA

Publication Date: October 1998

In implementing a cross-facility initiative, the importance of planning and understanding the implications for all facilities can't be overlooked. Here's how one integrated delivery network navigated the challenges of implementing a cross-facility enterprise master patient inde....