Author: AHIMA

Source: AHIMA practice brief

Publication Date: August 2012

Editor’s note: This update replaces the June 2010 practice brief “Verbal/Telephone Order Authentication and Time Frames.”


It is important for a healthcare facility to review and understand all applicable federal and state laws and accreditation standards when de....

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....

Author: Tegen, Anne; O'Connell, Jennifer

Source: Journal of AHIMA

Publication Date: January 2012

Using scribes to document patient encounters for physicians offers both benefits and challenges. A pediatric hospital recounts its experience adding scribes to its inpatient rounding teams.

The use of scribes to assist providers with documentation is gaining popularity for....

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....

Author: Rollins, Genna

Source: Journal of AHIMA

Publication Date: January 2011

While EHRs offer improvements to patient care, they are not documentation panacea for record keeping. Systems must be properly configured and used to generate solid documentation. When they are not they might not represent what actually occurs in patient care, compromising care and complicatin....

Author: AHIMA

Source: AHIMA practice brief

Publication Date: June 2010

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

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....

Author: e-HIM Work Group on Benchmark Standards for Clinical Coding Performance Measurement. Quality Subgroup

Source: AHIMA practice brief

Publication Date: March 2008

This practice brief has been retired. It is made available for historical purposes only.

Author: Denny, Susan

Source: Journal of AHIMA

Publication Date: January 2008

Electronic work queues capture incomplete records, enabling quality improvement initiatives to do more, more easily.



More than two years ago Jupiter Medical Center went live with an electronic record and retrieval system. The system allows users to scan and v....

Author: AHIMA EHR Practice Council

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: October 2007

This practice brief has been retired. It is made available for historical purposes only.

Author: Rollins, Gina

Source: Journal of AHIMA

Publication Date: May 2007

Paper copies of electronic records pose more than administrative hassles, they raise liability concerns as well.
As healthcare providers move closer to fully electronic health records, paper remains, frustratingly, part of the equation.

Some elements, like authorizat....

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....

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....

Author: Micheletti, Julie A.; Shlala, Thomas J.

Source: Journal of AHIMA

Publication Date: February 2006

Hospitals typically know which physicians need documentation therapy. However, they do not always have a comprehensive care plan. A combination of educational and operational steps can improve physician contributions in the documentation requirements for hospital records.
Identifying Iss....

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.....

Author: E-HIM Work Group on Maintaining the Legal EHR

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: November 2005

This practice brief has been retired. It is made available for historical purposes only.

Author: Curtis, Elizabeth

Source: Journal of AHIMA

Publication Date: October 2005

As CPOE turns from vision to reality, what impact is it having on HIM? And what impact is HIM having on it?
Installing an order entry system in a busy hospital environment can be a huge undertaking for administration, information systems, nursing, ancillary departments, and the medical s....

Author: Rode, Dan

Source: AHIMA testimony and comments

Publication Date: May 23, 2005

May 23, 2005

Mark McClellan, MD, PhD
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-3122-P
PO Box 8010
Baltimore, Maryland 21244-1850
Dear Dr. McClellan:
The purpose of this lett....

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....

Author: Russo, Ruthann

Source: IFHRO Congress | AHIMA Convention

Publication Date: October 15, 2004

Introduction

The absence of complete documentation in patient medical records can have a negative effect on statistical databases, financial planning, clinical preparedness, and gross revenue for the healthcare organization. It is for this reason that every healthcare organization should....

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....

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....

Author: Clark, Jean S.

Source: Journal of AHIMA

Publication Date: June 2004

For years health information managers have coordinated ongoing record reviews. From the early days of “clinical pertinence” review to the most recent “19 items” review, the jury is still out as to whether the process really improved documentation. With the Joint Commis....

Author: Kootenai Medical Center Credentials Committee

Source: AHIMA Foundation

Publication Date: December 16, 2003

Medical Staff Policy
PURPOSE: To define the guidelines associated with Delinquent Medical Records
OVERSIGHT BY: Credentials Committee
DEFINITIONS:
Delinquent:
Records are delinquent following 21 days in a physician's "box".
Exclusion from the KMC Campus:
S....

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....

Author: Fietz, Shirley; Michelman, Mark S.

Source: AHIMA sample form

Publication Date: June 02, 2003

Author: Glondys, Barbara

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: May 2003

This practice brief has been retired. It is made available for historical purposes only.

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....

Author: Russo, Ruthann; Dunleavy, Kathleen

Source: AHIMA Convention

Publication Date: September 23, 2002

Author: Wiedemann, Lou Ann

Source: AHIMA Convention

Publication Date: September 23, 2002

Author: Dougherty, Michelle

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: September 2002

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

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....

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.
....

Author: Prophet, Sue

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: October 2001

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

Author: AHIMA Policy and Government Relations Team

Source: AHIMA testimony and comments

Publication Date: July 27, 2001

On Friday, July 27, 2001, AHIMA presented testimony to the Centers for Medicare and Medicaid Services (CMS). As part of this testimony, AHIMA cited a new Practice Brief titled "Developing a Physician Query Process."

The practice brief is a keystone of AHIMA's recommendation to CM....

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: 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....

Author: Dougherty, Michelle

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: February 2001

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

Author: Dougherty, Michelle

Source: AHIMA practice brief attachment

Publication Date: February 2001

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

Author: Rapp, Timothy J.

Source: Educational Perspectives (AOE)

Publication Date: January 02, 2001

Introduction


Medical record documentation is one of the central aspects of healthcare today. Whether that documentation is in a paper-based system or in an electronic version makes no difference. The medical record is at the core of almost all healthcare functions. For example,....

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....

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....

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....

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....

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....

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....

Author: Yoder, Lois M.

Source: Journal of AHIMA

Publication Date: June 1999

Good documentation is a must in all settings—but long term care faces some special problems. Improving a long term care documentation program takes education, awareness, vigilance, and attention to detail. Here are some strategies.
It's a fact—when patient loads are hig....

Author: Doyon, Cynthia; Thompson, Kim; Meottel, Lori

Source: Journal of AHIMA

Publication Date: May 1999

Best practices don't have to be expensive or difficult. Sometimes changing a process for the better simply means looking at it from a new angle. Here's how one hospital staff collaborated on simple changes that made a difference.

When it comes to reengineering processes....