Author: Kearney, David

Source: Journal of AHIMA

Publication Date: February 2014

At a minimum healthcare organizations should identify the components of their legal health record. The legal health record is a consistent declaration of what patient care information is maintained within an organization and what information would be released during a legal or investigato....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: January 2014

Patient matching and identity management has been a critical component of health information management (HIM) since the beginning of the profession, when master patient indices (MPI) were kept on 3x5 inch index cards. HIM professionals don’t have to be told about the challenges with dupli....

Author: Fenton, Susan H.; Joost, Elizabeth; Gongora, Jimena; Patterson, Davis G; Andrilla, C. Holly A; Skillman, Susan M

Source: Educational Perspectives in Health Informatics and Information Management

Publication Date: December 2013

Abstract


The widespread implementation of electronic health records (EHRs) has resulted in an increased need for a well-trained health information technology (HIT) workforce. The Texas HIT Workforce Development Project was initiated with an assessment of HIT employer needs as one....

Author: AHIMA

Source: AHIMA report

Publication Date: November 2013

This thought leadership paper explores the relationship of data mapping and data integrity assurance by providing guidance to avoid adverse outcomes involving the use of maps.

Author: Landsbach, Grant; Just, Beth Haenke

Source: Journal of AHIMA

Publication Date: November 2013

In recent years health information exchange (HIE) has emerged as a trusted model for sharing patient information across hospitals and health systems to drive improved care coordination and, ultimately, quality and outcomes. The result of the convergence of advanced health information techn....

Author: David, Gary; Vinkhuyzen, Erik

Source: Journal of AHIMA

Publication Date: November 2013

Documents are a fundamental component of any organization. In fact, no organization can exist without filing the proper paperwork. Documents are such a pervasive part of our everyday life that almost every parody of office work involves the specter of a burdensome documentation requirement....

Author: Kadlec, Lesley

Source: Journal of AHIMA

Publication Date: November 2013

Prior to the widespread implementation of electronic health records (EHRs), problem lists were usually maintained by physicians through a simple documentation tool in the paper record, such as a "front sheet" or by copying a diagnosis list to a specified area within the paper chart and pla....

Author: AHIMA

Source: AHIMA practice brief

Publication Date: October 2013

Editor's note: This update supersedes the August 2011 practice brief "Retention and Destruction of Health Information."



Health information management professionals traditionally have performed retention and destruction functions using all media, including paper, images, optic....

Author: Dooling, Julie A

Source: Journal of AHIMA

Publication Date: October 2013

Many hospitals and physician practices in the Oklahoma City area have been actively involved in adopting and building an electronic health record (EHR) infrastructure to qualify and attest to the “meaningful use” EHR Incentive Program. Moore Medical Center (MMC), a 45-bed commu....

Author: Van Doornik, William

Source: Journal of AHIMA

Publication Date: October 2013

There is growing interest within the healthcare payer community to promote patient engagement through various means, including the integration of patient-generated data into clinical care documentation and quality measures. This is evident in the suggestions for stage 3 "meaningful use" EH....

Author: U.S. Office of the National Coordinator for Health Information Technology

Source: Government (U.S.) | U.S. Office of the National Coordinator for HIT

Publication Date: September 2013

This guidance is meant to serve as a building block for federal agencies and stakeholders to use as they work with different communities to achieve interoperable electronic health information exchange.

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: September 2013

Introduction


Many technologies exist to assist with better clinical documentation and speech recognition technology (SRT) is one solution. Since SRT uses mathematic probabilities, the technology can be complicated. The goals of its use in healthcare today, however, are clear: Increase....

Author: AHIMA Work Group

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: August 2013

Editor’s note: This update replaces the 2007 practice brief “Guidelines for EHR Documentation to Prevent Fraud.”


Electronic documentation tools offer many features that are designed to increase both the quality and the utility of clinical documentation, enhancin....

Author: Cassidy, Bonnie S.

Source: Journal of AHIMA

Publication Date: August 2013

The unsustainable growth of health costs, the growing lack of access to healthcare, and increasing disparities in provided care have forced the US to change how healthcare is delivered. With multiple national initiatives facing the healthcare industry, it is a challenge for healthcare prof....

Author: AHIMA

Source: AHIMA toolkit

Publication Date: July 2013

This toolkit provides guidance in disaster planning and recovery, including release of information and record preservation, with the primary focus of collecting and protecting health information.

Author: Barnhouse, Torrey; Rudman, William J.

Source: Educational Perspectives in Health Informatics and Information Management

Publication Date: July 2013

Abstract


As healthcare reform and technology further define the role and work expectations of the health information management professional, the need for clinical documentation specialists (CDSs) is likely to expand. This article examines the current and potential growth of the C....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: July 2013

Information quality, better access to health information, and greater information exchange are in store for eligible providers, eligible hospitals, and critical access hospitals expecting to attest to stage 2 of the Centers for Medicare and Medicaid Services’ (CMS) “meaningful....

Author: Chtourou, Helen

Source: Journal of AHIMA

Publication Date: July 2013

A key focus of clinical documentation improvement (CDI) programs is to identify deficiencies in clinical documentation and develop methods to ensure the complete and accurate capture of a patient’s clinical encounter. Healthcare records that are inaccurate or incomplete will compromi....

Author: Towers, Adele L

Source: Journal of AHIMA

Publication Date: July 2013

The following is likely not a surprise to those clinical documentation improvement specialists (CDS) working day in and day out improving physician documentation. But for the record-clinical documentation improvement (CDI) is not taught in medical school. The truth is that most physicians....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: July 2013

Clinical documentation requirements are expected to increase as healthcare systems are challenged with complex new audits, ever-changing compliance rules, and a transition to ICD-10-CM/PCS. All of these initiatives will specifically challenge clinical documentation improvement (CDI) profes....

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: Crawford, Mark

Source: Journal of AHIMA

Publication Date: July 2013

HIM professionals have been looking for some truth and straight talk on computer-assisted coding (CAC). The technology has been billed as everything from the savior of coding-based bottom lines due to ICD-10-CM/PCS (ICD-10) to the automated destroyer of human coding jobs. As the technology....

Author: U.S. Office of the National Coordinator for Health Information Technology

Source: Government (U.S.)

Publication Date: June 26, 2013

Author: Bowman, Sue E

Source: AHIMA testimony and comments

Publication Date: June 18, 2013

testimony on new uses of ICD-10 data

Author: Scott, Karen S.

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2013

As the healthcare industry prepares for the transition to ICD-10-CM/PCS, many tools have been developed to assist in mitigating anticipated coding productivity losses. Computer-assisted coding (CAC) is an important tool that healthcare organizations can leverage to help counteract projecte....