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Migrating from Paper to EHRs in Physician Practices. Appendix A: Historical Medical Record/Chart Abstraction Checklist—Primary Care

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: November 2010


This checklist can help physician practices migrate all the appropriate data from an individual patient paper record into the EHR. Each record or data element should be expanded upon with descriptions based on the practice’s definitions, the location of the information in the paper chart,....

Migrating from Paper to EHRs in Physician Practices - Retired

Author: AHIMA

Source: AHIMA practice brief

Publication Date: November 2010


A successful transition from paper-based charts to electronic health records (EHRs) in the physician practice or clinic requires careful coordination of many moving parts. A myriad of challenging and complex decisions must be made, ranging from selection and implementation to training and maint....

Mobile Device Use, Reuse, and Disposal

Author: Southerton, Laurie

Source: Journal of AHIMA

Publication Date: June 2007


The healthcare industry increasingly communicates via technology. Mobile devices are becoming prevalent in many organizations to the point where many staff find it difficult to work without them.

The HIPAA privacy and security rules require the private and secure handling of patient....

Mobilizing to Do Adaptive Work

Author: Fletcher, Donna M.

Source: Journal of AHIMA

Publication Date: November 1999


Can our visionary leaders solve our problems? Sometimes. But more often, the reality is the power to solve problems lies with us. This is the fundamental assumption of the "adaptive work" concept presented in this article—along with some real-life examples of HIM adaptive work in action.....

Navigating a Compliant Breach Management Process

Author: Downing, Katherine

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: June 2014

The purpose of AHIMA’s new Breach Management Toolkit is to provide a comprehensive collection of resources and best practices to help healthcare organizations and health information management (HIM) professionals navigate their way through the Health Insurance Portability and Accountability Act (HIPAA) Breach Notification Rule and the overall breach management process. The toolkit is intended to raise awareness of the importance and responsibility of everyone within the organization to report HIPAA breaches to the appropriate designated personnel, as well as provide breach prevention education and training.

New Approach to Chargemaster Management

Author: Richey, John

Source: Journal of AHIMA

Publication Date: January 2001

After examining their CDM management processes, HIM professionals, along with clinical and support departments, redesigned and automated several practice aspects with successful results. (FORE Best Practice, AHIMA Foundation)

New Focus on Process and Measure: Raising Data Quality with a Standard Coding Workflow and Benchmarks

Author: Wilson, Donna D; Hampton-Bagshaw, Kim; Jorwic, Therese M; Bishop, Jean; Giustina, Elizabeth

Source: Journal of AHIMA

Publication Date: March 2008




Establishing a standard coding workflow that incorporates continuous improvement and creating performance benchmarks is key to improving the quality of coded data.



HIM professionals who assign codes or manage coded data take responsibility for translating clinical....

New Health Information Management (HIM) Competencies? Teaching Critical Thinking Using an Unfolding Case Study

Author: Tyczkowski, Brenda

Source: Educational Perspectives in Health Informatics and Information Management

Publication Date: May 2015


Abstract


With the AHIMA Foundation’s establishment of new professional competencies for health information management (HIM) comes the opportunity to reimagine how lessons are presented to students. The use of unfolding case studies fosters a learner-centered classroom, where the s....

New Study Illuminates the Ongoing Road to ICD-10 Productivity and Optimization

Author: Alakrawi, Zahraa M; Watzlaf, Valerie J.M.; Nemchik, Scot; Sheridan, Patty Thierry

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: March 2017



To quantify the impact of ICD-10-CM/PCS (ICD-10) on coding productivity, Ciox Health, in partnership with the University of Pittsburgh’s Department of Health Information Management, School of Health and Rehabilitation Sciences, conducted a previous study published in the August 2016....

Off-Site Coding Success Story

Author: Kramer, Lynette; Meeks, Richard

Source: Journal of AHIMA

Publication Date: January 2000


If you asked HIM professionals about key success factors that substantially impact timely and accurate coding, three of the most common answers might be:
availability of the record immediately after the patient visit
availability of the complete record....

Online Records Serve Patients, Clinicians, and HIM

Author: Foster, Erica; Martin, Holly; Partin, Mary; Lockshaw, Jim; Fogelman, Adam; Folz-Murphy, Nancy; Harris, C Martin

Source: Journal of AHIMA

Publication Date: September 2003


Patients want online access to their health information but clinicians and HIM professionals don’t need any more work. The solution? An online medical record driven by the EHR. Here’s one organization’s success story.

If your own increasing Internet usage isn’t p....

On the Line

Author: Hjort, Beth M.

Source: AHIMA Q and A | Journal of AHIMA

Publication Date: April 2004


Q: Please explain the new Joint Commission requirement for “do not use” abbreviations, acronyms, and symbols. Does this mean that the abbreviation list requirement is being reinstated?

A: Standards have not required an approved list since 1991. IM.3 does require standard....

On the Line (January 2005)

Author: Quinsey, Carol Ann

Source: Journal of AHIMA

Publication Date: January 2005


Q: What is medical informatics, and is there a connection between it and health information management?

Q: Is there a standard addressing who should document in medical records?

Carol Ann Quinsey (carol.quinsy@ahima.org) is a professional practice manager at AHIMA.Article....

On the Line (November-December 2004)

Author: Burrington-Brown, Jill

Source: Journal of AHIMA

Publication Date: November 2004


Q:> As a covered entity, do I need to have satisfactory assurance (as required by HIPAA) that an individual has been notified when I am served with a search warrant for a patient's protected health information (PHI)?
Q: From a Washington State Community of Practice discussion thread: Wh....

On the Line (September 2004)

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: September 2004


Q: We are having trouble with the discharge status codes on some of our claims. In order to get the claim paid, the fiscal intermediary (FI) requires the discharge status code be changed. If we change the code, it will not correspond with documentation in our medical record.
Q: We are h....

On the Line: Professional Practice Solutions

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: June 2002


Q: Is it true that the method for calculating the delinquent chart rate has changed and it is no longer necessary to carry a delinquent chart from month to month?
Q: Recently, a discharged patient fell two days after discharge from the inpatient rehab facility where I work. He went to the....

On the Line: Professional Practice Solutions

Author: Hughes, Gwen

Source: Journal of AHIMA

Publication Date: March 2002


Q: Does the individual to whom a patient has granted durable power of attorney for financial matters have the right to access and authorize use or disclosure of the patient's protected health information (PHI) under HIPAA?


Q: We have a transcriptionist who picks up tapes, trans....

On the Line: Professional Practice Solutions

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: November 2002


Q: Where can I find federal regulations, interpretive guidelines, and Medicare manuals online?
Q: Where can I find information regarding auto-authentication?
Q: When should a change to scanned documents in an information system be identified as a late entry?
Michelle Dougherty (....

On the Line: Professional Practice Solutions

Author: Burrington-Brown, Jill

Source: Journal of AHIMA

Publication Date: January 2003


When is it legal to disclose protected health information (PHI) to clergy?
Is faxing patient information legal under HIPAA?
Does HIPAA allow clinicians in our home health facility to pull their own records?
What is a "shadow record?"
Jill Burrington-Brown (jill.burrington-b....

On the Line: Professional Practice Solutions

Author: Hughes, Gwen

Source: Journal of AHIMA

Publication Date: April 2002


Q: The physician practice I work for often receives photocopies of health information sent in anticipation of a new patient consultation or appointment. If the individual never presents to the practice, how long must our practice retain this health information?
Q: My facility is bringing....

On the Line: Professional Practice Solutions

Author: Hughes, Gwen

Source: Journal of AHIMA

Publication Date: September 2002


Q: What is a virtual shredder?

Q: A developmentally disabled adult was recently admitted to our hospital. The patient was accompanied by his older sister. The sister indicated her brother could not write but that he could draw an "X." Because the patient doesn't have a court-appointe....

On the Line: Professional Practice Solutions

Author: Welch, Julie J.

Source: Journal of AHIMA

Publication Date: April 1998


Q: I have a deposition scheduled for next week. The issue at hand is whether a preprinted manufacturer's instruction sheet on how to use a piece of medical equipment should be a part of the medical record. Our position is that it should not be included because it does not reflect wha....

On the Line: Professional Practice Solutions

Author: Fuller, Sandra R.

Source: Journal of AHIMA

Publication Date: March 1998


Q: Cellular phones are very popular and are a convenient way to increase communication. Should we place any restrictions on the use of cellular phones to discuss patient information?

Q: In light of last year's changes to the Joint Commission's standard on delinquent records, h....

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