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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....

CPOE Lessons Learned

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: October 2010


Hospitals and healthcare providers acknowledge that computerized physician order entry (CPOE) systems effectively address patient safety issues such as medication errors and document legibility. Built-in clinical decision support alerts can help identify drug-to-drug interactions or dosage err....

ICD-9-CM Coding Guidance for LTC Facilities - Retired

Author: AHIMA

Source: AHIMA practice brief

Publication Date: October 2010


Diagnostic coding plays several important roles in every healthcare setting, including long-term care (LTC) nursing facilities. LTC facilities assign ICD-9-CM codes to capture a resident's clinical conditions.


ICD-9-CM facilitates the collection and organization of healthcare stat....

Integrating Medical and Dental Records: A New Frontier in Health Information Management

Author: Rudman, William J.; Hart-Hester, Susan; Jones, Warren A.; Caputo, Nadine; Madison, Mary

Source: Journal of AHIMA

Publication Date: October 2010


Integrating records of systemic and oral health would improve patient care. It would also open up a new frontier in health information management.

A fully integrated patient record and care model for both systemic health (medical) and oral health (dental) is needed for health informa....

EHRs Prove a Difficult Witness in Court

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: September 2010


Sep 24, 2010

The EHR is a valuable clinical tool for streamlining and improving patient care. But it is complicating and confusing the courts.

As the first cases involving electronic health records make their way into legal proceedings, everyone involved is discovering th....

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