Search Results

= Members only

Current search

308 results.

[1] 2 3 4 5 6 7

Boosting Efficiency in Home Health Record Systems

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....

Telling the Patient Health Story

Author: AHIMA

Source: AHIMA Today

Publication Date: October 06, 2009


While many forms of valuable clinical data can be entered into an EHR in a structured way, some documents like transcribed physician notes remain trapped within unstructured electronic documents.

These transcribed notes and other narrative documents can be viewed through the EHR, bu....

Appropriate Use of the Copy and Paste Functionality in EHRs

Author: AHIMA

Source: AHIMA position statement

Publication Date: March 2014

Use of the copy and paste functionality in EHRs can result in redundant, erroneous, and/or incomprehensible health record documentation. Misuse of this functionality has the potential to result in or contribute to several overarching challenges, with implications for the quality and safety of patient care, medico-legal integrity of the health record, and fraud and abuse allegations.

AHIMA Offers Tips, Tools for Auditing in Long-term Care

Author: AHIMA

Source: Journal of AHIMA

Publication Date: November 2001


Once upon a time, the role of the medical records department in a long-term care (LTC) facility was to file and assemble discharge records. Those days are long gone. Today, it is critical for HIM practitioners to focus on the content and quality of the documentation in the medical record.
....

Auditing Copy and Paste

Author: AHIMA

Source: Journal of AHIMA

Publication Date: January 2009




For organizations that allow carrying forward clinical documentation, auditing its use is a key part of ensuring document integrity.




Copying clinical documentation can be a time-saver for busy clinicians. It also can pose a risk to document integrity. For org....

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....

Web FAQ

Author: AHIMA Coding Team

Source: AHIMA Q and A

Publication Date: October 2002

Where Can I Find Coding Guidelines for Use in Long Term Care or for Skilled Nursing Facility Reporting?

The official coding guidelines (see earlier question regarding who has the official guidelines for code assignment) are applicable in long term care. These guidelines have been develope....

Guidelines for EHR Documentation to Prevent Fraud. Appendix C: Steps to Prevent Fraud in EHR Documentation

Author: AHIMA e-HIM Work Group: Guidelines for EHR Documentation Practice

Source: AHIMA web extra

Publication Date: January 02, 2007


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



Preventing fraud due to the deliberate falsification of information when electronic health records (EHRs) are used requires three primary conditions....

Assessing and Improving EHR Data Quality: Model for Implementing an EHR Documentation Improvement Process

Author: AHIMA e-HIM Work Group on Assessing and Improving Healthcare Data Quality in the EHR

Source: Journal of AHIMA

Publication Date: March 2007


Improving data quality in an electronic healthcare environment requires a greater focus on standardized documentation procedures. With an EHR, the need to evaluate and improve healthcare data quality through concurrent assessment, data collection monitoring, and ongoing process improvement requ....

Journal Q&A (3/98)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: March 02, 1998


Q: In light of last year's changes to the Joint Commission's standard on delinquent records, how do I compute my delinquent record rate?


A: Last year the Joint Commission reduced the prescriptive nature of the language regarding delinquent records. Only the total number of ....

Journal Q&A (11/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2000

Q: Is it acceptable to use "canned" reports in transcription?
A: To the extent that outlines or phrases common to one or more providers in assessments and procedures are routine, they can and should be used to assist providers in documenting thoroughly and efficiently. How....

Journal Q&A (7/03)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: July 02, 2003

Q: When is a new history and physical (H&P) needed when moving a patient between an acute care bed to a swing bed?

A: The key to determining when an H&P is needed is to find out how the swing bed is being used and the regulations that apply. Section 1883 of the Social Security Ac....

Journal Q&A (11/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2000

Q: When a patient who was assaulted names her assailant, should the nurse or physician include the assailant's name in the medical record?
A: It is not uncommon for a healthcare provider to document in the record what the patient says when the information has some bearing on his or....

Web FAQ

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: October 2002

What are the documentation requirements for Observation Patients?
It is interesting to note that the observation service (OBS) did not originate from the government but by the healthcare marketplace in response to PPS/DRG conditions. When hospitals are not sure whether a patient will meet admi....

Web FAQ

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: October 2002

What guidance is available for determining an organization's definition of "attending physician" or "physician of record"?
The Department of Health, Education, and Welfare adopted the UHDDS (Uniform Hospital Discharge Data Set) as department policy for Medicare and Medicaid patient populations....

Journal Q&A (5/98)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: May 02, 1998


Q: With the revised method of calculating my delinquent rate for Joint Commission, are undictated operative reports (Ops) and H&Ps counted as delinquent?

A: Even though the Joint Com-mission's standard on how to calculate delinquency rates changed, the standards regardi....

Journal Q&A (2/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: February 02, 2000

Q: When does an incomplete record become delinquent?
A: An incomplete record is one in which any element of the record is incomplete or inaccurate and can be completed or corrected by the healthcare provider. A delinquent record is an incomplete health record that has remained inco....

Journal Q&A (1/05)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: January 02, 2005

Q: Is there a standard addressing who should document in medical records?
A: The answer to this question is left up to individual organizations. Most facilities create a policy that covers who can document in a patient’s medical record. This may also be covered in the medical staff bylaw....

[1] 2 3 4 5 6 7