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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....

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....

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....

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 (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....

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....

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....

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....

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 (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....

Journal Q&A (4/98)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: April 02, 1998


Q: I have a deposition scheduled for next week. The issue at hand is whether a preprinted manufacturer's instruction sheet on how to use a piece of medical equipment should be a part of the medical record. Our position is that it should not be included because it does not reflect ....

Journal Q&A (7/00)

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....

Journal Q&A (11/02)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2002

Q: When should a change to scanned documents in an information system be identified as a late entry?

A: An entry is not considered "late" in a set time frame. Generally, an entry should be made as close to the event as possible. The more time that passes, the more suspicious and vulnerab....

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 (10/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: October 02, 2000

Q: Can an emergency room exam serve as an inpatient history and physical?
A: It's important to understand the intent of the standards and regulations for hospitals and the practice standards for content of a history and physical (H&P) exam. The 2000 Joint Commission on Accreditation ....

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 (2/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: February 02, 2000

Q: The ambulatory care facility where I work is considering implementing an electronic signature process. Is the use of electronic signature acceptable in ambulatory care? Also, what guidelines for this are available?
A: The use of electronic signatures is acceptable to the Joint Comm....

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 (5/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: May 02, 2000

Q: Within what time frame are verbal orders required to be authenticated?
A: The Joint Commission on Accreditation of Healthcare Organizations' standard IM.7.7 for hospitals requires that "each verbal order must be dated and identified by the names of the individuals who gave it and....

Journal Q&A (6/02)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: June 02, 2002

Q: Is it true that the method for calculating the delinquent chart rate has changed and it is no longer necessary to carry a delinquent chart from month to month?
A: The method for calculating the delinquent chart rate has not changed. The Joint Commission confirmed that it considers a chart d....

Journal Q&A (4/01)

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....

Journal Q&A (3/02)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: March 02, 2002

Q: My facility administers flu vaccines to patients without requiring a scheduled appointment. Must the vaccine consents obtained be filed in the individual’s health record and how long should we retain them?


A: Consent forms are indeed part of an individual’s legal health....

Journal Q&A (3/02)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: March 02, 2002


Q: Is it important to get a new do not resuscitate (DNR) order when a patient is transferred with a DNR order from another facility?


A: It would be best to obtain a new DNR order. The patient or legal representative may have changed his or her mind or assume that your facility....

Journal Q&A (6/00)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: June 02, 2000

Q: How are hospitals reducing or maintaining low numbers of delinquent medical records?
A: Maintaining low numbers of delinquent records has long been a challenge for HIM professionals. Following are a few places from which to glean ideas: The AHIMA practice brief "Best Practices in Medical R....

Journal Q&A (6/01)

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....

Problem List Guidance in the EHR

Author: AHIMA Work Group

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: September 2011


Problem lists facilitate continuity of patient care by providing a comprehensive and accessible list of patient problems in one place. Problem lists used within health records are a list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifyi....

Unique Patient Identifiers -- What Are the Options?

Author: Appavu, Soloman I.

Source: Journal of AHIMA

Publication Date: October 1999


HIPAA has brought patient identifiers into the spotlight. But what's the best option? The author of a national study offers an overview.
Envision all of the players in the healthcare system—patients, providers, health plans, and payers. Now, envision all of the day-to-day processes t....

"Chutes and Ladders" of the Revenue Cycle: Strategies to Understand Data and Coding Quality Issues That Impact Your Ability to Successfully Play the Revenue Cycle Game

Author: Bauman, Carrie M.

Source: AHIMA Convention

Publication Date: October 15, 2004

Introduction

Since 1991, I have made a career in health information management. I entered the profession in the roles of assistant director and director of medical records in the acute care setting. After installing a Windows-based chart tracking system and a document imaging system, I f....

Meaningful Use and Clinical Documentation

Author: Benson, Sean

Source: Journal of AHIMA

Publication Date: February 2011


Little direct attention has been paid to clinical documentation in the context of meaningful use. Discussion and debate instead focused on electronic health records (EHRs), computerized physician order entry, and other health IT systems.

However, the electronic capture and exchange....

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