605 results.
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How to Prepare the Record for an E-Discovery Request
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....
Will the Real John Smith Please Stand Up?
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....
Health Information Technology Employer Needs Survey: An Assessment Instrument for Workforce Planning
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....
Data Mapping and Its Impact on Data Integrity
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.
Five Risky HIE Practices that Threaten Data Integrity
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....
Medical Records' Dynamic Nature: If It Isn't Written Down, It Didn't Happen. And If It Is Written Down, It Might Not Be What It Seems
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....
Resolving Problem List Problems: HIM’s Role in Maintaining an Effective EHR Problem List
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....
Retention and Destruction of Health Information
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....
Meaningful Use and Disaster Infrastructure Q&A: HIM Professionals Share Lessons Learned
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....
Meaningful Use of Patient-Generated Data in EHRs
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....
Certification Guidance for EHR Technology Developers Serving Health Care Providers Ineligible for Medicare and Medicaid EHR Incentive Payments
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.
Speech Recognition in the Electronic Health Record (2013 update)
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....
Integrity of the Healthcare Record: Best Practices for EHR Documentation (2013 update)
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....
The Next HIM Frontier: Population Health Information Management Presents a New Opportunity for HIM
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....
Disaster Planning and Recovery Toolkit (2013)
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.
Growth in the Clinical Documentation Specialist Profession
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....
CDI Programs Support Meeting Meaningful Use
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....
CDI Programs Used to Improve Quality Reporting Accuracy
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....
Clinical Documentation Improvement—A Physician Perspective: Insider Tips for getting Physician Participation in CDI Programs
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....
Strategizing Clinical Documentation Improvement: Tracking the Right CDI Measures, Data Can Impact Multiple Healthcare Areas
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....
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....
Truth about Computer-Assisted Coding: A Consultant, HIM Professional, and Vendor Weigh in on the Real CAC Impact
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....
Update on the Adoption of Health Information Technology and Related Efforts to Facilitate the Electronic Use and Exchange of Health Information
Author: U.S. Office of the National Coordinator for Health Information Technology
Source: Government (U.S.)
Publication Date: June 26, 2013
Testimony of the American Health Information Management Association to the National Committee on Vital and Health Statistics – Standards Subcommittee
Author: Bowman, Sue E
Source: AHIMA testimony and comments
Publication Date: June 18, 2013
testimony on new uses of ICD-10 data
Leveraging CAC to Prepare for ICD-10-CM/PCS
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....
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