53 results.
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Verbal/Telephone Order Authentication and Time Frames (2012 update)
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....
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....
Rounding with Scribes: Employing Scribes in a Pediatric Inpatient Setting
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....
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....
Diagnosing Documentation Ailments: Errors in Configuration and Use Compromise Electronic Records
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....
Verbal/Telephone Order Authentication and Time Frames (2010 update)
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.
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....
Collecting Root Cause to Improve Coding Quality Measurement
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.
Queuing up for Quality: Boosting Quality with Electronic Work Queues
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....
Developing a Legal Health Record Policy
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.
Printing Electronic Records: Managing the Hassle and the Risk
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....
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....
Documentation Rx: Strategies for Improving Physician Contribution to Hospital Records
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....
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.....
Maintaining a Legally Sound Health Record: Paper and Electronic
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.
Physician Order Entry Goes Online: the Effect on Records and HIM Operations
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....
AHIMA Comments on the Proposed Rule Changes to the Medicare and Medicaid Hospitals Conditions of Participation (COP)
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....
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....
Documentation and Data Improvement Fundamentals
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....
"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....
Clearing Up the Confusion: Ongoing Record Reviews for 2004
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....
Delinquent Medical Records Policy
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....
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....
Monitoring Incomplete/Delinquent Medical Records
Author: Fietz, Shirley; Michelman, Mark S.
Source: AHIMA sample form
Publication Date: June 02, 2003
Ensuring Legibility of Patient Records
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.
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....
Evolution and Implementation of Clinical Documentation Improvement
Author: Russo, Ruthann; Dunleavy, Kathleen
Source: AHIMA Convention
Publication Date: September 23, 2002
Joint Commission: How to Be a Survivor!
Author: Wiedemann, Lou Ann
Source: AHIMA Convention
Publication Date: September 23, 2002
Maintaining a Legally Sound Health Record
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.
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....
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.
....
Developing a Physician Query Process (2001)
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.
AHIMA Testifies to CMS on Physician Query Forms
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....
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....
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....
HIM Professionals and Patient Safety: How to Positively Influence Change
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....
Verbal/Telephone Order Authentication and Time Frames (2001)
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.
Verbal/Telephone Order Authentication and Time Frames (State regulations)
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.
Student Corner: The Pathology Report: a Cause of Delinquent Records
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,....
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 (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....
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 (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....
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....
When Bad Documentation Happens to Good Long Term Care Facilities
Author: Yoder, Lois M.
Source: Journal of AHIMA
Publication Date: June 1999
Good documentation is a must in all settingsbut 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 factwhen patient loads are hig....
Changes for the Better: Implementing Four Best Practices
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....
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