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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....

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....

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....

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....

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....

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.....

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....

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....

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....

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