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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 ....

On the Line: Professional Practice Solutions

Author: Carpenter, Jennifer E.

Source: Journal of AHIMA

Publication Date: May 1998


Q: I am currently employed by an organization that is implementing a long term care demonstration program for the frail elderly. I am in charge of the database for the demonstration. I'm writing policies and procedures for release of information and confidentiality and would like to ha....

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....

Best Practices: What Works

Author: Carrier, Danielle

Source: Journal of AHIMA

Publication Date: July 1999




Medical record accuracy, record completion time, physician satisfaction—all of these are indicators of how well an HIM department is performing. The findings of a UHC benchmarking study may point the way to best practices that can be shared and adapted.

What....

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....

Mastering the Information Management Standards

Author: Clark, Jean S.

Source: Journal of AHIMA

Publication Date: February 2000


For HIM professionals working at organizations surveyed by the Joint Commission on Accreditation of Healthcare Organizations, the information management standards are critical. Here's an overview of the key points and top issues surveyors look for.
Whether you work in acute, long term, h....

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....

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 (6/00)

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 (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....

On the Line: Professional Practice Solutions

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....

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....

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.
....

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 (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....

Physician Record Completion Policy

Author: Lutz, Laurie J.

Source: AHIMA Foundation

Publication Date: December 16, 2003


The HIM Department has a commitment to provide accurate, timely and friendly customer service.
Our goal is to strive for excellence in our day-to-day activities. With this in mind the following is how we achieved our success in decreasing the numbers of delinquent medical records.
D....

Seizing the Moment to Improve the Quality of Health Information Management

Author: Goshen, Naomi; Nachmani, Frances ; Sasson, Nadine ; Itzchak, Tzipi ; Sayfan, J; Kopelman, D; Kolton, L; Vigder, L; Almog, D; Tiosano, T

Source: IFHRO Congress | AHIMA Convention

Publication Date: October 15, 2004

Introduction

The need for accurate and complete records pertaining to operative procedures and diagnoses in surgery wards is almost self-evident. It is so because human life issues are at stake and erroneous and incomplete documentation may harm follow-up treatment as well as research da....

"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....

Re-abstraction Studies to Assess Data Quality for Use in the Development of a Grouping Methodology

Author: Mitchell, Sandra; Bartoli, Holly

Source: IFHRO Congress | AHIMA Convention

Publication Date: October 15, 2004

Purpose

The purpose of this paper is to provide an overview of the data quality re-abstraction studies that have been conducted in Canada. These studies provide a baseline of reliability for clinical administrative data submitted to the Discharge Abstract Database (DAD). Canada began a s....

Practice Toolkit: Medical Record Completion

Author: Hirsch, Ronald

Source: Journal of AHIMA

Publication Date: January 2006


Medical record completion compliance has always been a problem at Sherman Hospital, a medium-sized community hospital in Elgin, IL. The number of incomplete charts often exceeded the standard set by the Joint Commission on Accreditation of Healthcare Organizations, risking a type I violation.....

Perfect Time for Documentation Improvement

Author: Hagland, Mark

Source: Journal of AHIMA

Publication Date: July 2006




When new IT systems come online, the time couldn’t be better to assess and improve clinical documentation.

Electronic health record system implementations offer a perfect opportunity to assess and improve an organization’s clinical documentation. The renewed attention is ne....

Policies and Procedures for a Legal EHR

Author: Quinsey, Carol Ann

Source: Journal of AHIMA

Publication Date: April 2007


As organizations move from paper to electronic health records (EHRs), one of the most critical steps is ensuring that there are policies that support the EHR as the legal health record.

Most managers know the importance of having up-to-date policies and procedures. Good pol....

Completing Charts in EHRs

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: January 2010


This issue the Journal introduces a new “Working Smart” column offering best practices for working in the e-HIM environment.

Since the advent of the HIM profession many have struggled with the chart completion process. In the paper environment, the process began with assembling mount....

Managing Physician Queries in the EHR

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: July 2011


Federal incentives provided for the meaningful use program under the American Recovery and Reinvestment Act are encouraging hospitals to adopt electronic health records (EHRs). Eighty percent of hospitals are planning to become meaningful users of EHR technologies in 2011, and the healthcare i....

Documentation Trends in the Health Record

Author: Dooling, Julie A

Source: Journal of AHIMA

Publication Date: March 2012


The meaningful use program is well under way, helping providers and organizations adopt EHRs to capture complete and comprehensive documentation. To qualify for incentives in stage 1, organizations have adjusted their documentation processes to meet certain objectives and measures and will con....