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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....

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....

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,....

Performing a Breach Risk Assessment - Retired

Author: AHIMA

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: September 2013


On August 24, 2009, the US Department of Health and Human Services (HHS) published 45 CFR Parts 160 and 164 Breach Notification for Unsecured Protected Health Information; Interim Final Rule to implement the breach notification provisions of the Health Information Technology for Economic and Cl....

Practice Brief: Ensuring the Integrity of the EHR

Author: AHIMA

Source: AHIMA practice brief

Publication Date: January 2019


Editor’s Note: This Practice Brief supersedes the August 2013 “Integrity of the Healthcare Record: Best Practices for EHR Documentation” and the May 2015 “Assessing and Improving EHR Data Quality” Practice Briefs.





Nearly 20 years have....

E- Discovery Litigation and Regulatory Investigation Response Planning: Crucial Components of Your Organization’s Information and Data Governance Processes

Author: AHIMA

Source: AHIMA practice brief

Publication Date: November 2013

I. What is E-Discovery?



E-discovery is defined as the pretrial legal process used to describe the method by which parties will obtain and review electronically stored information. The 2006 Federal Rules of Civil Procedure (FRCP) served to place electronically stored information (....

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....

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-10-CM/PCS Project Management Resources

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: October 2009


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



Transitioning to ICD-10-CM/PCS will be a major undertaking for healthcare organizations. Below are ICD-10-CM/PCS project management resources and templates that organizations can use to h....

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....

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.....

The 10 Security Domains (Updated 2013) - Retired

Author: AHIMA

Source: AHIMA practice brief

Publication Date: October 2013


Editor's note: This update supersedes the February 2004, February 2010, and May 2012 practice briefs "The 10 Security Domains."


In today's healthcare environment, HIM professionals must understand basic information security principles to fully protect the privacy of information. T....

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