Search Results

= Members only

Current search

417 results.

1 [2] 3 4 5

Understanding the HIE Landscape

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: January 2013


The health information exchange (HIE) landscape has changed dramatically since HIE and the Nationwide Health Information Network (NwHIN) was first conceptualized in 2001. The National Committee on Vital and Health Statistics (NCVHS) published recommendations in 2001 on nationwide electronic hea....

Using Medical Scribes in a Physician Practice

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: November 2012


With the push to develop and deploy electronic health records (EHRs) and the need for more detailed documentation, there is a growing concern in the medical community regarding the time expended to capture information-electronic or otherwise. The time providers spend during a patient visit capt....

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 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....

Problem List Guidance in the EHR

Author: AHIMA Work Group

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: September 2011


Problem lists facilitate continuity of patient care by providing a comprehensive and accessible list of patient problems in one place. Problem lists used within health records are a list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifyi....

Protecting Patient Information after a Facility Closure. Appendix D: Health Information Management Checklist for Acquisitions and Closures (2011 update)

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: August 2011


This document is intended to be used as a guide and is not intended to be all-inclusive. It should be adapted to the setting or organization type.

Purpose: To ensure appropriate health information management tasks are processed during the acquisition, closure, or dissolution of an org....

HIM Functions in Healthcare Quality and Patient Safety. Appendix A: Patient Safety and Quality Opportunities for HIM-IT Collaboration

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: August 2011


In today's world, HIM staff must work together with the IT department to ensure the confidentiality, availability, and integrity of health information. This teamwork can enable safe, high-quality care and the efficient provision of services.

Normally HIM professionals are not respons....

HIM Functions in Healthcare Quality and Patient Safety. Appendix C: HIM’s Role in Data Capture, Validation, and Maintenance

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: August 2011


A critical component of AHIMA's draft HIM Core Model, a robust description of the functions and opportunities open to current and future HIM professionals, is capture and maintenance of health data.1 HIM professionals are encouraged to assume a leadership role in outlining how data are captured....

10 Security Domains (2011 update)

Author: AHIMA

Source: AHIMA practice brief

Publication Date: July 2011

This is the original web version of the practice brief, published in the May 2012 Journal of AHIMA. This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

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....

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....

ICD-9-CM Coding Guidance for LTC Facilities. Appendix B: Reporting and Sequencing Diagnoses on the Health Record and UB-04 Claim Form

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: October 2010


The "ICD-9-CM Official Guidelines for Coding and Reporting" is updated annually, thought it may be changed more frequently. Coders should be familiar with the guidelines and use the most current version.

The guidelines provide the following guidance for principal/first-listed and con....

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....

ICD-9-CM Coding Guidance for LTC Facilities. Appendix C: Regulatory Guidance for Reporting Diagnoses Related to Reimbursement

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: October 2010


In August 2000, the HIPAA Transaction and Code Sets required the use of the ICD-9-CM code set. Subpart J, section §162.1002 Medical data code sets, states the adoption of the following code sets as standard medical data code sets:
ICD-9-CM, volumes 1 and 2 (including the "ICD-9-CM Official....

Understanding the HIE Landscape

Author: AHIMA

Source: AHIMA practice brief

Publication Date: September 2010


The health information exchange (HIE) landscape has changed dramatically over the past five years. More HIEs are available to organizations and providers than ever before. Industry initiatives leveraging technological advances and the call for all Americans to have an electronic health record b....

1 [2] 3 4 5