Author: U.S. Agency for Healthcare Research and Quality

Source: Government (U.S.)

Publication Date: January 02, 2010

Author: Health Information Technical Standards Panel (HITSP)

Source: Government (U.S.) | U.S. Agency for Healthcare Research & Quality

Publication Date: January 02, 2010

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: Shams, Marie-Lise Antoun

Source: External web site

Publication Date: May 29, 2009

Author: Healthcare Information Technology Standards Panel (HITSP)

Source: External web site

Publication Date: January 04, 2009

Author: Paterno, Marilyn D.; Rynberg, Sally J.; Giannangelo, Kathy

Source: Journal of AHIMA

Publication Date: January 2009

It can be a challenge to keep straight the many terms used in events, concepts, or data in clinical records. The following table provides definitions for some of the many terms to help HIM professionals differentiate among them.

The difference between terminologies and vocabularies....

Author: Markle Foundation; Connecting for Health

Source: External healthcare industry report | External - used with permission

Publication Date: June 25, 2008

This document is part of The Connecting for Health Common Framework for Networked Personal Health Information, which is available in full and in its most current version here.

Author: AHIMA

Source: Journal of AHIMA

Publication Date: April 2006

This Software license agreement is entered into by and between Sample Software, Inc, a Delaware corporation with principal offices located at 100 Maple Lane, Chicago, Illinois 60601 ("Sample") and _________________, a corporation with principal offices located at ________________ ("Licensee") a....

Author: Fenton, Susan H.

Source: Journal of AHIMA - Coding Notes

Publication Date: May 2005

Coded data is the basis for knowledge transfer in 21st-century healthcare. The Unified Medical Language System (UMLS) is often called the Rosetta stone of international terminologies used in healthcare worldwide.

The purpose of the UMLS is to “facilitate the development of com....

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....

Author:

Source: External web site

Publication Date: January 02, 2004

Author: U.S. Agency for Healthcare Research and Quality

Source: U.S. Agency for Healthcare Research & Quality | External web site

Publication Date: January 01, 2004

Author: Canadian Institute for Health Information. Partnership for Health Information Standards

Source: External web site

Publication Date: January 01, 2004

Author: AHIMA Task Force

Source: AHIMA Task Force

Publication Date: October 20, 2003

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

Author: AHIMA Task Force

Source: AHIMA Task Force

Publication Date: October 20, 2003

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

Author: Erhardt, Walter L.; Medal, Diana

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2003

Recent advances in the science of wound healing are making an impact on the treatment of burns. This is particularly evident not only in the way burn wounds are being managed initially, but also in how these wounds are being reconstructed. While these scientific advances make this field an exc....

Author:

Source: AHIMA web extra

Publication Date: March 02, 2003

Administrative requirements of the privacy rule include those to have personnel designations, training, safeguards, complaint handling, sanctions, mitigation of harm, and current policies and procedures. These are not required if only summary information is exchanged between the GHP and plan sp....

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: October 2002

What guidance is available for determining an organization's definition of "attending physician" or "physician of record"?
The Department of Health, Education, and Welfare adopted the UHDDS (Uniform Hospital Discharge Data Set) as department policy for Medicare and Medicaid patient populations....

Author:

Source: Government (U.S.)

Publication Date: September 05, 2002

Author: Health Informatics Standards Board

Source: Government (U.S.) | U.S. Agency for Healthcare Research & Quality

Publication Date: July 17, 2002

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: May 02, 2002

Q: Is there a standard or recommended source for abbreviations used in medical records?


A: There is no standard or recommended abbreviation list. Because of service and style variation, healthcare organizations are encouraged to create their own customized list. An optimal approach....

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: November 02, 2001

Q: Where can I find an easy-to-use glossary for terms in the HIPAA regulations?


A: The Workgroup for Electronic Data Interchange (WEDI) has compiled an alphabetic glossary of HIPAA terms and definitions. It is approximately 24 pages long and can be downloaded from the WEDI Web sit....

Author: Prophet, Sue

Source: Journal of AHIMA

Publication Date: November 2000

The Health Insurance Portability and Accountability Act (HIPAA) presents numerous challenges to HIM processes and systems. Not least among these areas is coding. Among the concerns is whether the CPT system will be sufficient to meet the demands of HIPAA. The American Med....

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2000

Q: My facility wants to adopt or modify an existing abbreviation list rather than develop its own. Where can I locate such a list?
A: If you work in a community where the physicians practice at more than one facility, it would be ideal if those facilities shared a common abbreviation....

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: July 02, 2000

Q: What is a good source for looking up Internet-related terms?
A: One of the quickest and least expensive ways to look up an unfamiliar Internet term is by doing a search at www.whatis.com.

In addition to explaining terms such as "cookie" and "ISP," ....

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: January 2000

What will facilitate medical product regulation and related electronic data interchange worldwide? For some regulatory authorities, the answer is the Medical Dictionary for Drug Regulatory Affairs—also known as MedDRA.

MedDRA (the name is a trademark of the International Federat....

Author: Fletcher, Donna M.

Source: Journal of AHIMA

Publication Date: September 1999

From the onset of DRGs in 1983 through today's proliferation of prospective payment systems (PPS) and managed care efforts, the number of terms related to reimbursement has increased significantly. The following are some of those terms and abbreviations, including those r....

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: January 02, 1999

Q: I hear a lot of technical terms being used lately by information systems staff and I feel like I'm not speaking their "jargon." Could you clarify the meaning of some of these terms? Specifically, they are SQL, Java, TCP/IP, and IPX.

A: SQL stands for structured query language, whi....

Author: Humphreys, Betsy L.

Source: Journal of AHIMA

Publication Date: May 1998

A 1996-97 study conducted by the National Library of Medicine and the Agency for Health Care Policy and Research aimed to determine how well existing vocabularies cover the concepts and terms needed in health information systems. The author describes the hypothesis underlying the s....

Author: Harding, Ann; Stuart-Buttle, Charlie

Source: Journal of AHIMA

Publication Date: May 1998

Produced and maintained by Britain's National Health Service, the Read Codes are a comprehensive, controlled clinical vocabulary. Here's a look at how the codes evolved, their use in the NHS, and the continual process of aligning the system with the needs of its users.
<....

Author: Duffy, Philip G.

Source: Journal of AHIMA

Publication Date: February 1997

Healthcare is one of the most information-intensive industries in the economy but less automated than other industries such as banking and insurance. Modern healthcare delivery is governed by ad hoc teams of professionals assembled to address each case, which further complicates information a....