Author: Batterman, Christopher T.

Source: In Confidence (newsletter)

Publication Date: January 02, 2003

Few laws have created a bigger stir in the healthcare industry than HIPAA. While originally intended to simplify electronic transactions, HIPAA has broader implications. The need to ensure the privacy of medical information is a responsibility that touches most areas of the healthcare industr....

Author: Abraham, Prinny

Source: Journal of AHIMA

Publication Date: April 2000

The growing pains of the past decade have led to medical record backlogs and record retrieval crises for many home healthcare agencies. These problems have pushed more than one agency director into enlisting the skills of an HIM professional to evaluate the medical record systems in pl....

Author: Haines, Pamela T.

Source: Journal of AHIMA

Publication Date: September 1999

Operation PAR, Inc., in St. Petersburg, FL, is an integrated substance abuse/mental health delivery system that includes substance abuse programs and a recently acquired psychiatric hospital. It includes inpatient, residential, and outpatient programs for both juvenile and adult client....

Author: Joint Commission on Accreditation of Healthcare Organizations

Source: In Confidence (newsletter) | AHIMA Q and A

Publication Date: March 02, 2001

Q: Can staff of a healthcare organization, or their designated agent, film or videotape patient care activities in the Emergency Department? Does the staff have to get a patient’s consent to film or videotape their care while it is being provided?
A: Yes, to both questions. It is appropri....

Author: Doyon, Cynthia; Thompson, Kim; Meottel, Lori

Source: Journal of AHIMA

Publication Date: May 1999

Best practices don't have to be expensive or difficult. Sometimes changing a process for the better simply means looking at it from a new angle. Here's how one hospital staff collaborated on simple changes that made a difference.

When it comes to reengineering processes....

Author: Dinh, Angela K.

Source: Journal of AHIMA

Publication Date: April 2011

In the past several years cloud computing has gained substantial recognition. However, it is still a relatively new concept for those in the healthcare industry.

Before adopting cloud-based services or applications, organizations need to understand how cloud computing works, the typ....

Author: AHIMA Task Force

Source: AHIMA practice brief

Publication Date: October 2003

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Author: Swope, Shana

Source: Journal of AHIMA

Publication Date: June 2000

After Medicare regulations and the accompanying paperwork threatened to overwhelm an outpatient rehabilitation center, staff took steps to simplify the recertification process. The result was improved efficiency plus increased commitment to the electronic medical record. He....

Author:

Source: Journal of AHIMA

Publication Date: May 1999

The Department of Defense issued a request for proposals (RFP) for a personal identification card that can be used in conjunction with systemwide computer-based patient records system. Currently, most chip-based smart cards hold eight to 16 kilobytes, but the department is looking for a ....

Author: Quinsey, Carol Ann

Source: Journal of AHIMA

Publication Date: September 2007

Capturing data digitally is one thing. Producing it later is another. Any organization required to produce electronic documentation for any reason—whether for discovery in a legal proceeding or disclosure in support of ongoing patient care—knows that producing documentation....

Author: Mahoney, Mary Ellen

Source: Journal of AHIMA

Publication Date: April 1997

What Is Document Imaging Technology?
Document imaging systems (DIS) are information systems that typically capture information stored on paper documents and provide immediate, simultaneous access to the information contained in the patient or business record. Data stored on paper document....

Author: Rhodes, Harry B.; Dougherty, Michelle

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: June 2003

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

Author: Myjer, D'Arcy; Madamba, Roderick

Source: AHIMA Convention

Publication Date: October 10, 2001

Introduction


As all of us realize, healthcare is slowly moving toward an electronic medical record environment. The reasons today are just as valid as they were 20 years ago: immediate access to the patient record, less time charting and more time caring for patients, better....

Author: McCarthy, Therese; Johnson, Marlene L.

Source: Journal of AHIMA

Publication Date: September 2002

HealthEast Care System in St. Paul, MN, began its journey toward an EHR in 1998 with the implementation of an online nursing documentation system in which nurses enter information using desktop and laptop computers and wireless devices. A network of integrated care services with three acute ca....

Author: Dooling, Julie A; Downing, Kathy

Source: AHIMA Convention

Publication Date: October 02, 2011

Under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, Stage I meaningful use incentives focus on electronically capturing health information in a structured format. While scanned images do not meet these requirements, electronic document management syst....

Author: Beck, Catherine A.

Source: Journal of AHIMA

Publication Date: June 2000

One of the newest ways to store medical records isn't available to most HIM departments. For military personnel, the Personal Information Carrier (PIC) or "digital dog tag" is a computer storage medium that can hold some or all of a service member's medical record. Roughly th....

Author: Horn, William S

Source: Journal of AHIMA

Publication Date: January 2010

The Electronic Discovery Reference Model (EDRM) project offers guidelines and standards for e-discovery. It has helped reduce the cost, time, and manual work associated with e-discovery and has proven to be invaluable to those engaged in litigation support since its creation in 2005.

Author: AHIMA Task Force

Source: AHIMA practice brief

Publication Date: October 2003

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

Author: Burgess, Barbara

Source: Journal of AHIMA

Publication Date: June 1999

How does a busy student health center on a state university campus implement an electronic health record? This is the story of how Hall Health Primary Care Center (HHPCC), a community-based primary care center at the University of Washington (UW) in Seattle, did just that.

Author: Odom-Wesley, Barbara

Source: Journal of AHIMA

Publication Date: November 2000

Increasingly, patients are becoming interested in maintaining their own personal health records. What should these records contain? A panel of experts offers their recommendations.
When was the last time you or a member of your family moved, changed doctors, or saw a specia....

Author: Datskovsky, Galina; Hedges, Ron; Empel, Sofia; Washington, Lydia

Source: Journal of AHIMA

Publication Date: September 2015

Editor’s Note: This is the final installment in a series of four articles that discuss the eight Information Governance Principles for Healthcare™.


AHIMA’s Information Governance Principles for Healthcare™ (IGPHC) provide a framework for healthcare organizations to enhance....

Author: VanOver, Jennifer; Lusk, Katherine

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: November 16, 2016

When health information management involved keeping paper records in file rooms, a rule of thumb was that after two years with infrequent activity, medical records were often moved to off-site storage. This reduced the cost of maintaining medical records onsite long term. The records often....

Author: White, Jim

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: April 20, 2017

One of the more significant healthcare trends we see today is the consolidation (mergers and acquisitions) of hospitals, physician groups, and insurance companies into larger integrated systems. The goal of this activity have been focused on: increased market share, increased financia....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: September 2014

It’s midnight, and your cough has been unrelenting. You power up your laptop and visit one of the many websites that feature online access to physicians 24/7. Within minutes, you’re engaging in a video consultation with a board-certified physician who evaluates you, provides clinical inst....

Author: DeMasters, Dana; Deanna, Peterson

Source: Journal of AHIMA

Publication Date: February 2016

A police officer with a body-worn camera records video of an altercation in an emergency department involving a patient who has become violent. During the recording another patient not involved in the altercation has their image captured. The officer leaves the facility wit....

Author: Curtis, Clayton; Fenton, Susan H.

Source: Journal of AHIMA

Publication Date: April 1996

Introduction

Clinical data repositories (CDRs) are becoming the patient records of today and the foreseeable future. It is already clear that all clinical information, regardless of its origin (provider, patient, or even the computer itself), will someday be stored in a data repository (....

Author: Wolter, Julie

Source: Journal of AHIMA

Publication Date: October 2007

Many patients have their personal health information scattered across various practitioners and settings. Personal health records (PHRs) can help patients keep track of all their medical information. There are many different PHR products and models available today.


Cu....

Author: Kalata, Marcia

Source: Journal of AHIMA

Publication Date: October 1998

Five years ago, if someone had told me my organization would construct a new building without a chart room and would require half as many medical record clerks and that coders would work without stacks of charts at their desks, I'd have thought they were from a different planet. But....

Author: Servais, Cheryl

Source: Journal of AHIMA

Publication Date: September 2003

In January 2003, the Joint Commission made 11 recommendations for patient safety. HIM professionals play critical and supporting roles in implementing these recommendations. This article will discuss some of the recommendations, with examples of their use in various aspects of an HIM departmen....

Author: Bechert, Londa

Source: Journal of AHIMA

Publication Date: September 2002

St. Vincent Hospital and Health Services in Indianapolis, IN, is a member of the Ascension Health network, a nationwide Catholic health ministry. The HIM department has centralized responsibility for the main campus (650 beds) in Indianapolis, the St. Vincent Carmel Hospital (65 beds), and mul....

Author: Myjer, D'Arcy; Madamba, Roderick

Source: Journal of AHIMA

Publication Date: October 2002

The benefits of a document imaging system are myriad once it's installed—it's the implementation that you need to prepare for. In this article, get a bird's eye view of one facility's implementation and the many lessons learned along the way.

Healthcare has been inching toward....

Author: Graham, Debra

Source: Journal of AHIMA

Publication Date: February 2000

More and more is being seen and heard about the computerized patient record (CPR). The desire to embrace this new technology is often checked by fear of such a project's magnitude. A myriad of questions regarding computer literacy suddenly emerge: Do I, or anyone in my department, really under....

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: July 1997

The ability to provide timely, relevant, and accurate in-formation to the healthcare decision maker at the point of care is a critical success factor for any provider. For enterprises that operate in extremely competitive healthcare markets, the ability to meet this challenge could mean the d....

Author: Downing, Kathy; Fahy, Kristi; Foster, MeShawn; Hermann, Michelle; Meehan, Ann M.; Washington, Lydia; Woebkenberg, Jami

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: February 2017

When an organization begins to implement an enterprise information governance (IG) program, one of the major initial tasks is to understand the scope and types of information in its possession. An inventory of an organization’s information is necessary in order to facilitate decision maki....

Author: Johnson, Robert J.

Source: In Confidence (newsletter)

Publication Date: June 02, 2002

Death and taxes are often jokingly referred to as the only sure things in life. However, for the purposes of this article, I’d like to offer three additional scenarios: Hard-copy records of patient information will be created in abundance and in many different forms.
Those records will e....

Author: Graham, Gail; Nugent, Linda; Strouse, Kathleen

Source: Journal of AHIMA

Publication Date: March 2003

How does the nation's largest integrated healthcare system manage health information? Here, learn how HIM professionals helped the Veterans Health Administration take advantage of EHR technology to improve care.
Think of a healthcare system with 163 medical centers, more than 850 ambulato....

Author: U.S. General Accounting Office

Source: Government (U.S.)

Publication Date: October 30, 2003

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: October 02, 2001

Q: The nursing department has asked the HIM department for assistance in creating an organized process for thinning inpatient charts. Is there a standardized method that I could suggest?

A: HIM professionals are often asked for guidance in determining chart thinning practices, setting....

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: October 02, 2001

Q: Are there standards for establishing chart document order either during or after hospitalization?

A: Similar to chart thinning, there are no universal standards for chart order. Healthcare organizations are encouraged to develop a standardized arrangement that works well in offerin....

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: May 02, 2000

Q: Is electronic record storage legal?
A: HCFA authorizes computerized health records as long as they are maintained in a form that can be reproduced legally. In addition, the Medicare Conditions of Participation for Hospitals, Medical Records Services specify that hospitals must use....

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: July 02, 2000

Q: Where should informed consent forms for research and research-related access to patient records be filed?
A: As a general rule, records of informed consent or refusal to consent are filed in a patient's record. However, a notebook containing the following information can be valua....

Author: Bernstein, William

Source: Journal of AHIMA

Publication Date: July 2008

Providing consumers access to their health information seems like a simple concept. In reality, it is fraught with challenges. Records are still largely in paper form, and gaining access to them means contacting multiple parties and paying significant fees. Even when records are in electronic....

Author: Srinivasan, Anil

Source: Journal of AHIMA

Publication Date: January 2006

As Web-based personal health record (PHR) systems grow in popularity, it is important that they be managed and maintained responsibly. Online PHRs must provide the same security and privacy controls required of other electronic systems that handle personal health information. This article pres....

Author: Journal of AHIMA Staff

Source: Journal of AHIMA

Publication Date: March 2017

Crumbling, decaying, and abandoned hospitals aren’t just physically dangerous examples of urban decrepitude—they also could be prime targets for medical identity thieves who know what they’re doing.


Take the case of Chicago, IL’s Edgewater Medical Center, a....

Author: Okamoto, Carole

Source: Journal of AHIMA

Publication Date: October 1998

As health information expands beyond the traditional paper-based medical record, HIM professionals need to confront the issues related to defining the medical record. The author provides a detailed assessment guide to the redefinition process.
The Washington State Health Inf....

Author: Carol, Ruth

Source: Journal of AHIMA

Publication Date: April 2006

EHRs demonstrated their promise during Hurricane Katrina. But the storm's greatest lesson for HIM is the necessity of contingency planning for health information.
By now we've heard numerous stories about the piles of pulp that used to be patient medical records and the shelves of mildewe....

Author: Fujimura, Martin K.

Source: In Confidence (newsletter)

Publication Date: March 02, 2000

If one were to ask if a handwritten or printed paper medical record should remain confidential, most people- including individuals without medical or legal training-would agree that information should not be released without the patient’s consent or the existence of a valid medical emergency.....

Author: Palkie, Brooke

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: March 16, 2017

As I begin digging into the intricacies of long-term digital preservation (LTDP) of electronic healthcare data, I am realizing how little I knew. The ever-changing formats and standards for accessing personal health information (PHI) come to mind. Once obsolete, how will this information b....

Author: Reinke, Brian

Source: In Confidence (newsletter)

Publication Date: July 02, 2002

Now a proven technology, data warehousing is entering into widespread use. Detailed patient records of many organizations are now being electronically archived using data warehousing. The goal of using this computer technology is to retain information for years so it can be used for various m....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: March 2011

Managing third-party requests for health information is a routine function for every HIM department. HIM professionals regularly receive record requests from third parties for a variety of reasons, such as revenue integrity audits or admission validation reviews.

Historically, fulfi....

Author:

Source: AHIMA online training

Publication Date: May 17, 2011

This webinar addresses the management of legacy systems around patient care and compliance directives, how to manage, retain and maintain legacy systems to limit the amount of lost data, and preserve important data to expedite legal cases and payments.

Author: Carpenter, Jennifer E.

Source: AHIMA practice brief

Publication Date: February 1998

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

Author: Nunn, Sandra L.

Source: Journal of AHIMA

Publication Date: March 2008

Many of today’s healthcare entities have hybrid medical records, and policies abound describing what parts of the record are still accessed in paper and what components are now fully electronic. Wherever healthcare organizations are in the race to create fully accessible and secure elect....

Author: Medicare Learning Network

Source: U.S. Centers for Medicare & Medicaid Services

Publication Date: August 10, 2010

Author: Hagland, Mark

Source: Journal of AHIMA

Publication Date: October 2002

Many healthcare facilities are exploring document imaging solutions and enjoying the benefits of increased accessibility and faster workflows. The transition requires significant planning, however. In this article, learn how several healthcare organizations implemented document imaging systems....

Author: Bowers, Donna

Source: AHIMA Convention

Publication Date: September 23, 2002

Author: Schoenfelt, Suzanne

Source: Journal of AHIMA

Publication Date: September 1998

Are smart cards a viable solution for storing patient information? What about companies that store and provide emergency medical information? The author examines the possibilities these services offer.





These days, wallets are bulging with a proli....

Author: Kramer, Lynette; Meeks, Richard

Source: Journal of AHIMA

Publication Date: January 2000

If you asked HIM professionals about key success factors that substantially impact timely and accurate coding, three of the most common answers might be:
availability of the record immediately after the patient visit
availability of the complete record....

Author: Hjort, Beth M.

Source: Journal of AHIMA

Publication Date: October 2001

Q: The nursing department has asked the HIM department for assistance in creating an organized process for thinning inpatient charts. Is there a standardized method that I could suggest?



Q: Are there standards for establishing chart document order either during or....

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: September 1998

Q: My facility will begin imaging its paper medical records as part of the migration toward a computerized patient record. I am a member of the planning committee that is responsible for preparing the RFP and seeking out possible vendors. I have heard of optical imaging but have never had the....

Author: Brandt, Mary D.

Source: Journal of AHIMA

Publication Date: October 1994

Just how optical storage-based document imaging systems fit with the vision of the computer-based patient record (CPR) is the subject of some debate. To help AHIMA members better understand the issues involved, a workgroup was formed to address this issue. Included were representatives from A....

Author: Keeler, Joy; Galanter, William

Source: AHIMA Convention

Publication Date: September 23, 2002

Author: Carpenter, Jennifer E.

Source: AHIMA practice brief

Publication Date: January 1999

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Author: Hjort, Beth M.; Brandt, Mary D.; Carpenter, Jennifer E.

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: June 2001

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

Author:

Source: Journal of AHIMA

Publication Date: July 2000

Editor's note: APCs, risk management, knowledge management...all of these are practice issues that will affect the way HIM professionals work in the future. But practice solutions exist right now in our day-to-day work environments as well. Here are a few successful practice sol....

Author: Bowen, Rita K.

Source: In Confidence (newsletter)

Publication Date: February 02, 2003

As we continue to journey toward HIPAA readiness, a necessary step is identifying designated record sets (DRSs). DRSs are created to respond to patient requests concerning information used in making patient decisions. The definition of a DRS is any group of records (any item, collection, or g....

Author: Amatayakul, Margret

Source: Journal of AHIMA

Publication Date: June 2004

Encryption is an addressable implementation specification under HIPAA’s access control and transmission security standards. Many providers are grappling with just how to address these specifications:
Is there a difference between the two specifications, and if so, what is the diff....

Author: Rollins, Gina

Source: Journal of AHIMA

Publication Date: May 2007

Paper copies of electronic records pose more than administrative hassles, they raise liability concerns as well.
As healthcare providers move closer to fully electronic health records, paper remains, frustratingly, part of the equation.

Some elements, like authorizat....

Author: Dinh, Angela K.

Source: Journal of AHIMA

Publication Date: January 2011

The electronic health record's promise of a paperless environment has been around for decades, but it has proven difficult to keep. Regardless of how an EHR is implemented or the phase of implementation, paper remains a staple of the health record for quite some time after conversion and, in m....

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: August 2011

Author: Hughes, Gwen

Source: Journal of AHIMA

Publication Date: June 2001

As HIM professionals move toward paperless health records, our colleagues in radiology are making the transition to filmless records.

Those in predominantly paper-based ambulatory care environments know how challenging it is to make sure each patient record contains all th....

Author: Nunn, Sandra L.

Source: Journal of AHIMA

Publication Date: April 2008

Within the last decade, the domain of record retention management has exploded in response to the development of electronic records and their storage demands, the mandates emanating from regulations like HIPAA, and the emergence of e-discovery as the requisite method for compelling record prod....

Author: Hjort, Beth M.

Source: In Confidence (newsletter) | AHIMA Q and A

Publication Date: November 02, 2000

Question: What is the recommended practice for handling lost or missing paper records?
Answer: Since it is unknown whether missing records or components will be recovered, it is best to begin reconstruction immediately when you are sure the information is missing. Keep in mind that it is....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: May 20, 2015

As the costs associated with data storage and storage infrastructure continue to shrink—thanks to innovations such as cloud computing—individuals who manage records for a living must accept a new reality: destroying information and setting retention schedules will soon b....

Author: Brick, Frank

Source: Journal of AHIMA

Publication Date: April 2006

Computer systems are feeling the effects of HIPAA. That's because the act's privacy and security rules require covered entities to securely store and manage more data than ever before. The latest computers to feel the effect are those in small covered entities, where the security rule takes ef....