Author: Rhodes, Harry B.

Source: Behavioral Health

Publication Date: July 02, 2001

The new HIPAA privacy final rule mandate that affords a higher level of privacy restriction to psychotherapy notes is creating a fair amount of confusion for healthcare providers. Restricted access to mental health records should not be something new to health information management profession....

Author: Clark, Margi

Source: Brief Encounter

Publication Date: July 02, 2001

Here are some specific suggestions for improving the clarity and usefulness of physician record entries to support Evaluation and Management code levels.
History
Chief complaint with adjectives (8)
Site, description, severity, duration, timing (when) context (what is patient do....

Author: Udell, Curtis

Source: Brief Encounter

Publication Date: July 02, 2001

One of the constant challenges facing managers today is evaluating physician documentation and then helping their physicians to improve the content of their patient notes, particularly for evaluation and management (E/M) services.

While physicians may have unique style or flair to t....

Author: Skurka, Margaret A.

Source: Journal of AHIMA

Publication Date: July 2001

As HIM professionals know, accurate and complete documentation is critical for providing care and supporting reimbursement. This is particularly true-and yet particularly problematic-in the area of E/M coding. Medical practices report and are paid for their services using E/M coding, yet there....

Author: Smith, Cheryl M.

Source: Journal of AHIMA

Publication Date: June 2001

Q: Are there new Joint Commission hospital standards that address patient safety?


Q: What are the Joint Commission definitions of a sentinel event and root cause analysis?


Q: Where can I find information on completion of the medical record statistics form to det....

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: June 02, 2001

Q: Where can I find information on completion of the medical record statistics form to determine compliance with Joint Commission standard IM.7.6?

A: Standard IM.7.6 of the Joint Commission Accreditation Manual for Hospitals requires that medical record data and information are managed in....

Author: Roach, Daniel R.

Source: Journal of AHIMA

Publication Date: May 2001

In the 1970s, the defense budget consumed the largest share of the federal budget. Concerns about both the size and efficiency of the defense bureaucracy triggered a massive crackdown on federal contractors who had either intentionally or inadvertently failed to follow the Department....

Author:

Source: Brief Encounter

Publication Date: April 02, 2001

reprinted from Medicare Intermediary Manual

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: April 02, 2001

Q: What are the documentation requirements for the content of a discharge summary?

A: According to Documentation Requirements for the Acute Care Patient Record, the discharge summary is a recapitulation of events describing the patient's illness, investigation, treatment, response, and con....

Author: Holland, Julie A.

Source: Journal of AHIMA

Publication Date: April 2001

What are some of the common and not-so-common errors regarding patient safety known to HIM departments? Here are some of the most frequently seen errors and ways HIM professionals can contribute to a downturn in the number of adverse incidents attributable to problems involving docu....