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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 ....

Journal Q&A (3/98)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: March 02, 1998


Q: Cellular phones are very popular and are a convenient way to increase communication. Should we place any restrictions on the use of cellular phones to discuss patient information?

A: Cellular phones operate on radio frequencies, which means anyone tuning into that f....

Protection of Personal Data -- The European View

Author: Mathews, Steve

Source: Journal of AHIMA

Publication Date: March 1998


A new series of laws are being passed to control the processing of personal information -- including medical information -- inside the European Commonwealth. The author gives an overview of the European view of personal information and examines the implications for healthcare professionals bo....

Information Security--A Database View

Author: Zender, Anne

Source: Journal of AHIMA

Publication Date: March 1998



HIM professionals agree that applying the principles of information security is important in a hospital setting. But as Sharon Johnson, RRA, knows, those principles can be applied in many situations--including settings under construction. Since spring 1997, Johnson has been ....

New Standards Focus on Information Security

Author: Hanken, Mary Alice

Source: Journal of AHIMA

Publication Date: March 1998


The federal legislation for the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the need in healthcare for security of confidential data have come together to heighten the interest in security standards for electronic health information systems. Th....

Journal Q&A (4/98)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: April 02, 1998


Q: I am trying to find out if AHIMA has any position on the names and room numbers of hospitalized patients being left unattended at an information desk in a hospital lobby. If just the name and room number—no other information such as age, religion, etc.—is listed so that vi....

Journal Q&A (4/98)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: April 02, 1998


Q: I'm looking for any information regarding the identification of duplicate medical record numbers, or any articles that might address the process of merging MPI systems. Can you help me?

A: See AHIMA's practice briefs on master patient indexes: "Master Patient (Pers....

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 (4/98)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: April 02, 1998


Q: I have a practice question regarding sharing patient information with the state Department of Insurance. The ambulatory surgery center for which I work is having difficulty with several managed care companies that are not reimbursing our facility according to our contracts. It was....

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: The facility that I work for is planning to use an outside copy service. How can we be sure it will protect our patient information?

A: Start by evaluating the potential companies to ensure that they are reputable and provide quality services. Next, ask the various ....

Journal Q&A (5/98)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: May 02, 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 t....

To Sign or Not to Sign Verbal Orders

Author: Clark, Susan

Source: Journal of AHIMA

Publication Date: May 1998


The value of obtaining physician signatures on verbal orders after the patient's discharge from care is a concept that has been debated for several years. Typically, state regulations require that verbal orders be signed or authenticated. In some states a specific time frame—such....

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 (6/98)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: June 02, 1998


Q: What processes need to be developed to standardize data collection?


A: The list includes, but is not limited to, the following processes:
Appropriate education and training programs
Timely and appropriate communication of data definitions to those ....

Maximizing Data Quality of the Minimum Data Set

Author: Zender, Anne

Source: Journal of AHIMA

Publication Date: June 1998


HIM professionals who work in long term care settings are well acquainted with the Minimum Data Set 2.0 (MDS). Since 1990, it has been part of the standardized assessments that nursing homes participating in the Medicare and Medicaid programs must complete. Starting this summer, updated submis....

Journal Q&A (6/98)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: June 02, 1998


Q: How do you "validate" a data collection instrument?

A: The purpose of validating the data collection instrument—including paper forms and computer screens—is to:
ensure that the data collected will support the intent of collecting the data....

Comparative Data--Its Impact and Opportunities

Author: Bellile, Susan K.

Source: Journal of AHIMA

Publication Date: June 1998


A battle for control of medical management is now being waged among hospitals, managed care plans, insurers, employers, physician groups, and researchers—a battle in which data is the weapon of choice. Cumulative and comparative healthcare information is being used to eva....

On The Line: Professional Practice Solutions...

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: September 1998


Q: My facility will begin imaging its paper medical records as part of the migration toward a computerized patient record. I am a member of the planning committee that is responsible for preparing the RFP and seeking out possible vendors. I have heard of optical imaging but have never had the....

Long Term Care Meets Information Challenges

Author: Zender, Anne

Source: Journal of AHIMA

Publication Date: September 1998



As the Net surfers of today become the long term care consumers of tomorrow, the long term care industry faces new challenges. Patients and their families are growing increasingly interested in information that will help them make more informed decisions about healthcare. A....

Journal Q&A (9/98)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: September 02, 1998


Q: My facility will begin imaging its paper medical records as part of the migration toward a computerized patient record. I am a member of the planning committee that is responsible for preparing the RFP and seeking out possible vendors. I have heard of optical imaging but have never had the o....

HIM Metamorphosis

Author: Kalata, Marcia

Source: Journal of AHIMA

Publication Date: October 1998



Five years ago, if someone had told me my organization would construct a new building without a chart room and would require half as many medical record clerks and that coders would work without stacks of charts at their desks, I'd have thought they were from a different planet. But....

Implementing the Enterprise Master Patient Index

Author: Adragna, Lisa

Source: Journal of AHIMA

Publication Date: October 1998


In implementing a cross-facility initiative, the importance of planning and understanding the implications for all facilities can't be overlooked. Here's how one integrated delivery network navigated the challenges of implementing a cross-facility enterprise master patient inde....

IT Implementation Requires HIM Expertise

Author: Didear, Kay

Source: Journal of AHIMA

Publication Date: October 1998


Implementing a computer-based patient record (CPR) begins long before the first installment of software is loaded. This process significantly benefits from the skills and expertise health information management professionals bring to the table. But don't assume that your healthcare m....

Performance Improvement for Documentation

Author: Labak, Carol

Source: Journal of AHIMA

Publication Date: October 1998


We've all seen it before: that look of bewilderment on a physician's face when a discussion about documentation arises. While this is not the first incidence of this discussion between the physician and the health information manager, neither is it the first time the HIM professional ....

Government Moves Ahead with CPR Endeavor

Author: Blumenthal, Jane E

Source: Journal of AHIMA

Publication Date: October 1998


Though issues about establishing an inter-departmental computer-based patient record (CPR) between the Department of Defense and Department of Veterans Affairs (VA) have been on the table for a long time, real action toward a CPR began in November 1997, according to Colonel Lynn....

Journal Q&A (10/98)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: October 02, 1998


Q: Where can I find information about a system that will allow for the electronic transmission of Minimum Data Set (MDS) information?

A: One of the Health Care Financing Administration's (HCFA's) proposals relating to the MDS 2.0 resident assessment process requires lo....

Continuous Speech Recognition: What You Should Know

Author: Clark, Holly

Source: Journal of AHIMA

Publication Date: October 1998


Is speech recognition a futuristic dream, an emerging technology, or a current reality? How vital is speech input to a computerized patient record strategy? How can you influence your organization to investigate speech recognition options that best meet its needs? There are no simple answers t....

Journal Q&A (10/98)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: October 02, 1998


Q: I am currently serving on a team that is looking at re-engineering its patient cycle time (i.e., getting the patient in and out of the facility as quickly and efficiently as possible, without sacrificing patient/provider interaction). As we review our release of information processe....

State of the Computer-based Patient Record

Author: Amatayakul, Margret

Source: Journal of AHIMA

Publication Date: October 1998


Value, experiments, promises, disappointments, hype, compromises, and change all characterize the status of the computer-based patient record (CPR). An industry expert offers some perspective on where the CPR has been and where it's going.

In 1873, Florence Nightingale lamented her....

Components of the CPR: An Overview

Author: Martin, Tom; Fuller, Sandra R.

Source: Journal of AHIMA

Publication Date: October 1998


To better participate in the implementation of the CPR, it's important that HIM professionals understand the nuts and bolts of a system. Here's an overview from the ground up.
Across the nation, the implementation of computer-based patient record (CPR) progresses -- slowly but steadily.....

Working with an Incentive Program for Transcription

Author: Anderson, Jamelia

Source: Brief Encounter

Publication Date: November 02, 1998


After several months of planning, Smith-Glynn-Callaway, a multi-specialty clinic in Springfield, MO, implemented an incentive program for transcription. Since the inception of the program on March 16, great strides have been made. Previously, the medical transcriptionists worked many long hou....

Prescribing a Clean Bill of Health for Data

Author: Fletcher, Donna M.

Source: Journal of AHIMA

Publication Date: January 1999


Ensuring data quality is not really glamorous, but it is critical," Jane Griffin, vice president of business solutions for Prism Solutions in Atlanta, GA, maintains. "And nowhere is it more critical than in the healthcare environment."

A data warehouse can b....

Journal Q&A (1/99)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: January 02, 1999


Q: I hear a lot of technical terms being used lately by information systems staff and I feel like I'm not speaking their "jargon." Could you clarify the meaning of some of these terms? Specifically, they are SQL, Java, TCP/IP, and IPX.

A: SQL stands for structured query language, whi....

What Winning CPR Implementations Can Teach Us

Author: Fuller, Sandra R.

Source: Journal of AHIMA

Publication Date: January 1999



"Perhaps the single most important characteristic of successful CPR implementations is the view that the implementation is not finished, and that any CPR implementation is a means to achieve improvements in healthcare quality, cost, and access, not an end in itself."

&mdash....

CPR in Long Term Care

Author: Schoenfelt, Suzanne

Source: Journal of AHIMA

Publication Date: February 1999


Throughout the healthcare industry, the computer-based patient record (CPR) is in various stages of development. This article assesses the progress long term care facilities are making in moving toward the CPR. The article also suggests some ways HIM professionals can devel....

Building a Better CPR in Ambulatory Care

Author: Zender, Anne

Source: Journal of AHIMA

Publication Date: March 1999


In implementing a computer-based patient record (CPR), an organization must address these questions: How can we integrate what the product does with our own strategic vision? And how can we justify the cost of installing a system?

While it is not widely used, the evolu....

Implementing the CPR: A Journey

Author: Frohwerk, Art

Source: Journal of AHIMA

Publication Date: March 1999


Implementing a CPR system is a major change for any organization. The author offers an approach to managing this change, including critical factors, characteristics of winning solutions, and the highlights of this journey.

Many think of a CPR as merely a software and hardware "prod....

Sample Information Security Program

Author: Ballam, Holly

Source: Journal of AHIMA

Publication Date: March 1999


Information Security Program
XYZ Hospital
Effective Date      
         ..............................................................................................................................

1. Poli....

Desperately Seeking Smart Cards

Author:

Source: Journal of AHIMA

Publication Date: May 1999


The Department of Defense issued a request for proposals (RFP) for a personal identification card that can be used in conjunction with systemwide computer-based patient records system. Currently, most chip-based smart cards hold eight to 16 kilobytes, but the department is looking for a ....

OASIS Cracks Down on Home Care

Author: Carpenter, Jennifer E.

Source: Journal of AHIMA

Publication Date: May 1999



January 25, 1999, brought the publication of the final rule on the assessment and use of the Outcomes and Assessment Information Set (OASIS) in the Federal Register. This rule requires that each patient receive a patient-specific, comprehensive assessment that identifies the patient'....

Decimating Duplicates

Author: Gentry, Lynne; Harnish, Patricia A.

Source: Journal of AHIMA

Publication Date: June 1999


After approximately 150,000 (out of 787,000) medical record numbers in a master patient index (MPI) were identified as possible duplicates, MultiCare Health System in Tacoma, WA, decided to address the problem through a multidisciplinary approach. An MPI conversion to a new hospital in....

Medical Dictation: A New Generation

Author: Groner, Gabriel F.

Source: Journal of AHIMA

Publication Date: June 1999


As the term implies, automatic speech recognition is a computer's recognition of speech, automatically converting it into readable text and interpretable commands. To fully understand automatic speech recognition, one must first be aware of the distinction between speech recognition an....

EMR Education for a Student Health Center

Author: Burgess, Barbara

Source: Journal of AHIMA

Publication Date: June 1999


How does a busy student health center on a state university campus implement an electronic health record? This is the story of how Hall Health Primary Care Center (HHPCC), a community-based primary care center at the University of Washington (UW) in Seattle, did just that.

Post-acute PPS: Changing the Way We Code

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: June 1999


HIM professionals in post-acute care are reinventing their roles to accommodate the new coding demands of a prospective payment system. Here are some of the developments that are creating new interest in coding issues for post-acute settings.
Three major forces -- the prospective payment....

Common (and Uncommon) Ground

Author: Dixon-Lee, Claire

Source: Journal of AHIMA

Publication Date: June 1999


On a trip to Dublin this spring, I met with several officers of the Healthcare Informatics Society of Ireland. During this visit, we talked about health information management, finding common ground on topics like:
Year 2000 compliance
the need for clinical vocabulary....

On the Line: Professional Practice Solutions

Author:

Source: Journal of AHIMA

Publication Date: June 1999


Q: I work in a skilled nursing facility and want to know if it is mandatory for all states to use Resource Utilization Groups III (RUGS III). If so, when was the deadline?
Q: Where can I find information about a system that will allow for the electronic transmission of Minimum....

Automated Coding: The Next Step?

Author: Beinborn, Julie

Source: Journal of AHIMA

Publication Date: July 1999


Automated coding technology may be key to the evolution of the coding and billing processes. How do these systems work, and how will they change the role of the coder? The author offers a preview.
Technology is changing many aspects of healthcare, and coding is no exception.

R....

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....

Group Builds Consensus on Laboratory Test Policies

Author: Prophet, Sue

Source: Journal of AHIMA

Publication Date: July 1999


The Balanced Budget Act of 1997 (BBA) mandated that the Health Care Financing Administration (HCFA) use a negotiated rulemaking process to develop national administrative and coverage policies for clinical diagnostic laboratory tests under Medicare Part B. The BBA stipulates that the p....

HL7 Overview

Author: Quinn, John

Source: Journal of AHIMA

Publication Date: July 1999


As one of the co-developers of Health Level Seven (HL7), I am very close to the issue. So in describing it, I'm going to start with the basics, beginning with the current definition that has evolved over HL7's brief existence:

"The Health Level Seven (HL7) Standard, an ANSI approved....

Tools for Defining Data

Author: Shakir, Abdul-Malik

Source: Journal of AHIMA

Publication Date: September 1999


Similarly, data dictionaries, data sets, and data models have much in common, but many significant differences. Each can be used to define data, especially data that needs to get from point A to point B. This article describes each of these tools and the value they add to health information ma....

Intranets -- From EMR to ER and Beyond

Author:

Source: Journal of AHIMA

Publication Date: September 1999


In the article, "Next Generation: How Internet Technology Propels the Electronic Medical Record" (Journal of AHIMA, September 1999), we spotlighted a few of the many facilities using Web technology for the EMR. A complete list of facilities with similar systems is probably beyond the scope of t....

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