985 results.
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Role of the Personal Health Record in the EHR (2010 update) - Retired
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....
Role-based Model for ICD-10 Implementation: Academic Timeline for Prospective Students
Author: AHIMA
Source: AHIMA
Publication Date: November 18, 2009
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Electronic Signature, Attestation, and Authorship. Appendix C: Electronic Signature Model Policy (2013 update)
Author: AHIMA
Source: AHIMA practice brief attachment
Publication Date: October 2013
Recruitment, Selection, and Orientation for CDI Specialists
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....
EHRs as the Business and Legal Records of Healthcare Organizations (2010 update)
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.
Facsimile Cover Letter
Author: AHIMA
Source: AHIMA sample form
Publication Date: January 02, 1997
Sample Notice of Lost/Destroyed/Incomplete Patient Information (Disaster Planning)
Author: AHIMA
Source: AHIMA sample form
Publication Date: December 15, 2010
RFP Process for EHR Systems (2010 update)
Author: AHIMA
Source: AHIMA practice brief
Publication Date: July 2010
This practice brief has been retired. It is made available for historical purposes only.
HIM Functions in Healthcare Quality and Patient Safety. Appendix B: HIM’s Role in Data Governance
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....
HIPAA Internal Assessment for HIM Professionals
Author: AHIMA
Source: AHIMA sample form
Publication Date: May 02, 2000
Sample Notice of Health Information Practices
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.
The Privacy and Security of Occupational Health Records
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....
Understanding the HIE Landscape
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....
Electronic Signature, Attestation, and Authorship. Appendix B: Laws, Regulations, and Electronic Signature Acts (2013 update)
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....
Management Practices for the Release of Information (2012 update)
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....
Identifying Issues in Facility and Provider Mergers and Acquisitions. Appendix B: HIM Worklist: Setting Up a New Clinic
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....
Request for Correction/Amendment of Health Information
Author: AHIMA
Source: AHIMA sample form
Publication Date: January 02, 1997
ICD-9-CM Coding Guidance for LTC Facilities. Appendix A: Planning for the ICD-10-CM Transition for LTC Facilities
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....
EHR Adoption in LTC and the HIM Value. Appendix C: The HIM Professional as Privacy Officer in LTC
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....
Internet Resources for HIM Professionals (2010 update)
Author: AHIMA
Source: AHIMA practice brief
Publication Date: June 2010
This practice brief has been retired. It is made available for historical purposes only.
Sample Preemption Decision Form
Author: AHIMA
Source: AHIMA sample form
Publication Date: February 02, 2002
Protecting Patient Information after a Facility Closure (2011 update)
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....
EHR Adoption in LTC and the HIM Value - Retired
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....
EHR Adoption in LTC and the HIM Value. Appendix D: The HIM Professional as a Compliance Officer in LTC
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....
Sample Training Database
Author: AHIMA
Source: AHIMA sample form
Publication Date: January 02, 2002
Role-based Model for ICD-10 Implementation: Data Managers
Author: AHIMA
Source: AHIMA
Publication Date: November 18, 2009
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Guidance for Clinical Documentation Improvement Programs
Author: AHIMA
Source: AHIMA practice brief
Publication Date: May 2010
The content in this practice brief has been updated. See updated information here.
Understanding Publicly Available Healthcare Data (2013 update) - Retired
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....
EHR Adoption in LTC and the HIM Value. Appendix A: HIM’s Role and Functions in LTC
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....
Sample Contractural Agreement
Author: AHIMA
Source: AHIMA sample form
Publication Date: April 02, 2003
Enterprise Content and Record Management for Healthcare
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.
Understanding the HIE Landscape. Appendix A: State Health Information Exchange Cooperative Agreement Program
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.....
Managing Unsolicited Health Information in the Electronic Health Record
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.
Sample Preemption Decision Summary Log
Author: AHIMA
Source: AHIMA sample form
Publication Date: February 02, 2002
Putting the ICD-10-CM/PCS GEMs into Practice. Appendix A: Examples of Complexity in Applied Mappings
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....
Healthcare Reimbursement Audit Toolkit - Retired
(The content in this toolkit has been retired. It is made available for historical purposes only.)
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.
Copy Functionality Toolkit
Author: AHIMA
Source: AHIMA toolkit
Publication Date: June 06, 2012
HIM Functions in Healthcare Quality and Patient Safety
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....
Sample HIM Privacy and Security Training Plan
Author: AHIMA
Source: AHIMA sample form
Publication Date: November 02, 2003
Fundamentals for Building a Master Patient Index/Enterprise Master Patient Index (2010 update)
Author: AHIMA
Source: AHIMA practice brief
Publication Date: September 2010
This practice brief has been retired. It is made available for historical purposes only.
Electronic Signature, Attestation, and Authorship. Appendix D: Glossary of Terms (2009 update)
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....
Sample Amendment Policy: Amendments to Health Information in the Electronic Record
Author: AHIMA
Source: AHIMA toolkit
Publication Date: August 24, 2009
Limiting the Use of the Social Security Number in Healthcare. Appendix B: Federal Legislation Restricting SSN Use
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....
AHIMA Query Toolkit - Retired
Author: AHIMA
Source: AHIMA toolkit
Publication Date: April 2017
Limiting the Use of the Social Security Number in Healthcare. Appendix A: Chronological Order of SSN Legislation
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....
Using Medical Scribes in a Physician Practice. Appendix B: Sample Scribe/Provider Agreement
Author: AHIMA
Source: AHIMA practice brief attachment
Publication Date: November 2012
Putting the ICD-10-CM/PCS GEMs into Practice
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.
EHRs as the Business and Legal Records of Healthcare Organizations. Appendix B: Checklist for Transition to the EHR (2010 update)
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....
Information Security—An Overview (2010 update)
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.
Implementing the Enterprise Master Patient Index
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....
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