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

Author: AHIMA

Source: AHIMA practice brief attachment

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....

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....

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

Author: AHIMA

Source: AHIMA practice brief attachment

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....

Electronic Documentation Templates Support ICD-10-CM/PCS Implementation. Appendix C: Checklist for Template Review

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: October 2012


This checklist may be used by the requestor prior to submission of the template and by health information management services (HIMS) or the informatics department prior to the release of the template for testing. It could also be an electronic document used in conjunction with the request form.....

Electronic Record, Electronic Security

Author: Hagland, Mark

Source: Journal of AHIMA

Publication Date: February 2004


New technologies are enhancing the ability to protect patient information. But there’s more to successful implementation than just what’s inside the box.

Melanie Schattauer, RHIA, Jack Obert, and their colleagues at Mercy St. John’s Health System in Springfield, M....

Electronic Signature, Attestation, and Authorship. Appendix A: HL7 EHR-System Records Management and Evidentiary Support (RM-ES) Functional Profile Standard Excerpt (2009 update)

Author: AHIMA e-HIM Work Group: Best Practices for Electronic Signature and Attestation

Source: AHIMA practice brief attachment

Publication Date: November 2009


The records management and evidentiary support functional profile standard is a subset of functions and conformance criteria from the HL7 EHR-S Functional Model standard. The standard was created specifically to address requirements and criteria for basic record management functionality in EHR....

E-mail Best Practices Maximize Efficiency

Author: Barron, Dan

Source: Journal of AHIMA

Publication Date: November 2003


Can you imagine having to go to the fax machine every time you needed to send someone a message or document? Can you imagine if you had to write a letter and go through the process of “snail mailing” every time you wanted to reach out to someone professionally? True, the US Postal Se....

Employee/Student/Volunteer Nondisclosure Agreement

Author: AHIMA

Source: AHIMA sample form

Publication Date: June 02, 2003

Employee/Student/Volunteer Nondisclosure Agreement
[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 provide....

EMR Education for a Student Health Center

Author: Burgess, Barbara

Source: Journal of AHIMA

Publication Date: June 1999


How does a busy student health center on a state university campus implement an electronic health record? This is the story of how Hall Health Primary Care Center (HHPCC), a community-based primary care center at the University of Washington (UW) in Seattle, did just that.

Enhancing Patient Care through Data Analysis

Author: Spencer, Gregory

Source: Journal of AHIMA

Publication Date: June 2010


Healthcare organizations, just like individuals, can suffer from information overload. Increasingly tasked with linking quality data to reimbursement parameters, providers now attempt to capture every piece of possible data.

The problem is that data collection has a price tag. Someti....

Enhancing Practice Efficiency and Patient Care by Sharing Electronic Health Records

Author: Keller, Megan E; Kelling, Sarah E; Cornelius, Douglas C; Oni, Hafusat A; Bright, David R

Source: Perspectives in Health Information Management

Publication Date: 2015


Abstract


One primary function of community pharmacies is to dispense medications to patients. In doing so, pharmacists frequently communicate with physicians’ offices to clarify prescription orders and obtain additional information to ensure the safe and accurate dispensing of med....

Ensuring Privacy and Security in Home Health

Author: Demster, Barbara

Source: Journal of AHIMA

Publication Date: January 2007




Every healthcare provider must customize its privacy and security program to fit its unique setting and needs. How an organization maintains its records (analog, paper, electronic, or mixed modes) drives its privacy and security procedures. While regulations provide the basic requirem....

Enterprise Content Management from the Ground Up

Author: Nunn, Sandra L.

Source: Journal of AHIMA

Publication Date: February 2008


How a project that began with 50 policies and procedures critical to Joint Commission standards is growing into a content management system encompassing thousands of documents from across an organization.
Optimally healthcare organizations should arrive at an enterprise content management....

Establishing a CDI Program: How One Organization Leveraged Nursing and Coding Skills to Improve Clinical Data

Author: Lopez, Barbara A

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2010


Establishing a clinical documentation improvement (CDI) program is an organization-wide, transformational process that affects a hospital’s culture, reaching across all disciplines and touching every colleague and the way they perform their jobs. Many factors can lead healthcare organizations....

Ethical Standards for Clinical Documentation Improvement (CDI) Professionals (2016)

Author: AHIMA

Source: AHIMA

Publication Date: June 2016

The AHIMA Ethical Standards for Clinical Documentation Improvement Professionals are intended to assist in decision making processes and actions, outline expectations for making ethical decisions in the workplace, and demonstrate the professionals' commitment to integrity. They are relevant to all clinical documentation improvement professionals and to those who manage the clinical documentation improvement (CDI) function, regardless of the healthcare setting in which they work.

Ethics in Practice: Asking the Right Questions

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: March 2001


When was the last time you had to decide the right thing to do? Recall a time when an employee asked your advice about what action would be right or wrong. What words would you would use to describe how you made the decisions? Words like "judgement," "intuition," a....

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