Author: Bryant, Gloryanne H.; Mogbo, Chinedum

Source: AHIMA practice brief

Publication Date: July 2018

Untitled Document


Guidelines for Physician Office Query Practice


Documentation in the health record is a basic but critical component to every patient encounter, patient service, and setting. The provider is key to delivering detailed information reg....

Author: Watson, Monica M

Source: Journal of AHIMA | AHIMA practice brief

Publication Date: June 2018

Documentation and Coding Practices for Risk Adjustment and Hierarchical Condition Categories


Risk adjustment is a statistical process that considers the underlying health status and health spending of patients when examining their healthcare outcomes....

Author: AHIMA

Source: AHIMA practice brief

Publication Date: December 2017

Patient Name:_______________________________________________________________________

Date of Birth:________________________________________________________________________

Address: ____________________________________________________________________________

City:__________....

Author: Ewoterai, Okemena; Lusk, Katherine; Orlova, Anna; Young, Donna

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: November 2017

The proverbial comparison of “apples and oranges” is a well-known metaphor in casual conversation and discussion. When talking about expanding clinical documentation improvement (CDI) programs in today’s environment of electronic health records (EHRs) and information governanc....

Author: Hyde, Lynda; Casto, Anne B.; Koehler, Melissa; Lockwood, Famey; Peterson, Kathleen

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: September 2017

Healthcare is an evolving world where data is central to all aspects of care. It is an information-intensive environment where data analysis is used to make decisions about the quality and safety of patient care, public health programs, and healthcare reform. At the core....

Author: Combs, Tammy; Endicott, Melanie

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: July 2017

Physician engagement seems to be the buzzword in healthcare these days. Hospital administrators charged with various clinical improvement initiatives have come to realize that physician engagement is an essential element of success. While physician engagement in clinical documentation improveme....

Author: Comfort, Angie; Rugg, Donna; Ward, Maria

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: June 2017

Editor’s Note: This update replaces the 2010 Practice Brief “The Evolution of DRGs.”


In the early 1970s Yale University developed diagnosis related groups (DRGs) to describe all types of patient care in an acute care hospital. The Yale system encompassed the Medi....

Author: Barnette, Erin; Endicott, Melanie; Ericson, Cheryl E; Wieczorek, Michelle M.

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: May 2017

In order to effectively discuss clinical documentation improvement (CDI) opportunities in physician practices, it is important to first understand the drivers and goals of a physician practice CDI program. Historically, diagnosis codes have had little impact in regard to physician practice paym....

Author: Burton, Ben; Downing, Katherine

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: April 2017

Editor’s Note: This Practice Brief update supplants part of the 2013 Practice Brief “Patient Access and Amendment to Health Records.”


Before April 2003, a patient’s legal right to amend his or her health records was limited to those patients treated at hea....

Author: AHIMA Work Group

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: March 2017

One of the Healthy People 2020 objectives from the Office of Disease Prevention and Health Promotion is to improve the health, safety, and well-being of individuals in the lesbian, gay, bisexual, and transgender (LGBT) population.1 This population faces health disparities with barriers to healt....