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Risk Management 101

Author: Collins, Patricia

Source: Journal of AHIMA

Publication Date: October 1999


The decision to implement a computer-based patient record (CPR) system is a substantial commitment of time and resources. Making it a reality in your organization requires a number of steps, not the least of which is risk assessment. Assessing the risks associated with the CPR should ....

Unique Patient Identifiers -- What Are the Options?

Author: Appavu, Soloman I.

Source: Journal of AHIMA

Publication Date: October 1999


HIPAA has brought patient identifiers into the spotlight. But what's the best option? The author of a national study offers an overview.
Envision all of the players in the healthcare system—patients, providers, health plans, and payers. Now, envision all of the day-to-day processes t....

EMR ... CMR ... CPR ... G-CPR??

Author: Tadwalt, Bobbi

Source: Brief Encounter

Publication Date: October 02, 1999


Most of you have probably heard of the first few acronyms listed in the title; however, it is likely most of you have never heard of the G-CPR. Most people hadn't, until they attended the Multi-Specialty Group Educational Forum held in Baltimore, MD this past March. Robert M. Kolodner, MD, th....

New, Informed Public

Author: Dixon-Lee, Claire

Source: Journal of AHIMA

Publication Date: October 1999


The healthcare consumer is emerging as a strong force in today's healthcare industry. On a national level, current efforts for new and improved patients' rights legislation in the wake of complaints about access and rising costs, is placing the patient in a position of strength unlike....

Vision of Health Information Management in 2010

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: November 1999


Two-thirds of today's health information managers will be in the prime of their careers 10 years from now. But what will the world of work look like? One way to gain an understanding of the future is to create scenarios. Scenarios are literally stories about the future th....

Trend Watch: Coding for Nonphysician Services

Author: Hill, Emily

Source: Journal of AHIMA

Publication Date: January 2000


From physician assistants to nurse practitioners, the number of healthcare professionals offering patient care services has increased dramatically in recent years. With this increase comes a challenge to coders—accurately reporting the services provided by these prof....

Guarding Against Disclosure

Author:

Source: Journal of AHIMA

Publication Date: January 2000


The Agency for Health Care Policy and Research (AHCPR) is developing "guiding national principles" for assisting institutional review boards (IRB) and similar bodies to protect against the wrongful disclosure of personal health information that could be used to identify patients involved....

Off-Site Coding Success Story

Author: Kramer, Lynette; Meeks, Richard

Source: Journal of AHIMA

Publication Date: January 2000


If you asked HIM professionals about key success factors that substantially impact timely and accurate coding, three of the most common answers might be:
availability of the record immediately after the patient visit
availability of the complete record....

Journal Q&A (2/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: February 02, 2000

Q: What Internet security guidelines are available?
A: Initially, Medicare issued a statement that the Internet was not secure enough for transmission of sensitive data. However, the growing demand for transmittal of HCFA Privacy Act-protected data via the Internet resulted in HCFA's....

Implementing an Electronic Imaging System

Author: Graham, Debra

Source: Journal of AHIMA

Publication Date: February 2000


More and more is being seen and heard about the computerized patient record (CPR). The desire to embrace this new technology is often checked by fear of such a project's magnitude. A myriad of questions regarding computer literacy suddenly emerge: Do I, or anyone in my department, really under....

Steering Quality Improvement in Healthcare

Author: Schoenfelt, Suzanne

Source: Journal of AHIMA

Publication Date: February 2000


"Quality" is a multi-industry buzzword, but what does it really mean in today's healthcare climate? We asked the experts for their views on the state of quality improvement in healthcare and what lies in store for HIM professionals as QI evolves.
For decades, healthcare has concerned its....

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....

Journal Q&A (2/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: February 02, 2000

Q: The ambulatory care facility where I work is considering implementing an electronic signature process. Is the use of electronic signature acceptable in ambulatory care? Also, what guidelines for this are available?
A: The use of electronic signatures is acceptable to the Joint Comm....

Smart Cards for Healthcare: a Follow-up Visit

Author: Ross, Bruce

Source: In Confidence (newsletter)

Publication Date: March 02, 2000


Smart cards are a peculiar subject when it comes to healthcare in the United States. They are viewed as everything from an up-andcoming product to an inscrutable and hard to integrate backwater technology. Today, all that is rapidly changing. As shown by its adoption by Microsoft, Sun Micro,....

Resolving Confidentiality Barriers in Research Data Collection

Author: Houser, Shannon H.; Engle, Molly; Schumacher, Joseph E; Caldwell, Ellen; Kohler, Connie L; Phelan, Sharon T; Raczynski, James M; Reynolds, Kim D

Source: Journal of AHIMA

Publication Date: March 2000


How can HIM professionals ensure data collection consistency without access to earlier records? When protecting patient anonymity posed a challenge in a research study, HIM professionals took a team approach to abstracting records that maintained quality without compromising confidentiality.

AHIMA Comments on Privacy Rule

Author: Asmonga, Donald D.

Source: Journal of AHIMA

Publication Date: March 2000


On January 18, 2000, AHIMA submitted comments to the Department of Health and Human Services (HHS) on the proposed rule for 45 Code of Federal Regulations (CFR), Parts 160 through 164: "Standards for Privacy of Individually Identifiable Health Information." The proposed rule....

Last Rights: ROI and the Deceased

Author: Hughes, Gwen

Source: In Confidence (newsletter) | AHIMA Q and A

Publication Date: March 02, 2000


Question: Who can authorize the release of patient health information on behalf of a deceased patient?
Answer: The individual authorized to consent to the release of patient health information on behalf of a deceased patient varies by state. Usually, the personal representative of a dec....

Tracking HIV, Maintaining Confidentiality

Author:

Source: Journal of AHIMA

Publication Date: March 2000


In an effort to track the spread of HIV, the Centers for Disease Control and Prevention (CDC) released guidelines to assist states in collecting data on the disease. By using the names of patients who test positive for HIV or unique identifying codes, the CDC hopes to better track the ....

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....

Standards: Solutions or Culprits?

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: April 2000


No other country on earth has as regulated a healthcare system as the US, and no country on earth comes close to our level of health spending. According to one estimate, Medicare regulations span more pages than the notorious Internal Revenue Code.1

Are all these standards....

Journal Q&A (4/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: April 02, 2000

Q: When are rubber-stamp signatures acceptable? I read in a Part A newsletter that Medicare no longer accepts rubber-stamp signatures on documents that certify, order, or justify a service billed to Medicare. The newsletter cited the Medicare Conditions of Participation for hospitals (42CFR482.....

Health Informatics Standards: A User's Guide

Author: Brandt, Mary D.

Source: Journal of AHIMA

Publication Date: April 2000


From code sets to data sets to developing organizations, how much do you really know about technical standards? This article provides a handy reference guide.

The vision is clear: a longitudinal, or lifetime, health record for each person that is computer-based, secure, readily ac....

Clarifying Selected CPT Modifiers

Author: Scichilone, Rita A

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2000


Coding for professional services is complicated enough when coding professionals are charged with assisting the physician to select the best five-digit number for the services rendered. It becomes even more complex when circumstances of the case require the CPT code to be modified. Add....

Setting the Standards

Author: Jeffries, Jane

Source: Journal of AHIMA

Publication Date: April 2000


After years of learning and teaching HIM, Mary Alice Hanken, PhD, RHIA, now develops the standards that shape it. Hanken leads an American Society for Testing and Materials (ASTM) subcommittee that authors the standards that are changing the meaning of security.

Hanken has....

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 (5/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: May 02, 2000

Q: Is electronic record storage legal?
A: HCFA authorizes computerized health records as long as they are maintained in a form that can be reproduced legally. In addition, the Medicare Conditions of Participation for Hospitals, Medical Records Services specify that hospitals must use....

Compliance Efforts Lead to Process Improvements

Author: Swope, Shana

Source: Journal of AHIMA

Publication Date: June 2000




After Medicare regulations and the accompanying paperwork threatened to overwhelm an outpatient rehabilitation center, staff took steps to simplify the recertification process. The result was improved efficiency plus increased commitment to the electronic medical record. He....

"Dog Tags" Make Data Storage Easier

Author: Beck, Catherine A.

Source: Journal of AHIMA

Publication Date: June 2000


One of the newest ways to store medical records isn't available to most HIM departments. For military personnel, the Personal Information Carrier (PIC) or "digital dog tag" is a computer storage medium that can hold some or all of a service member's medical record. Roughly th....

IHC Eyes E-health Code of Ethics

Author: Asmonga, Donald D.

Source: Journal of AHIMA

Publication Date: June 2000


The privacy of personal information on the Internet is a hot topic nationwide. Is an e-health code of ethics in order? AHIMA and several other organizations are offering guidance this spring to the industry's first attempt at one.

Together with the American Medical Informa....

Journal Q&A (6/00)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: June 02, 2000


Q: I work for a small physician practice. Until recently, physicians would take home patient records to dictate in the evening. Unfortunately, one of our physicians' cars was burglarized and 30 records were stolen. What should we do?
A: The loss of this information could cause problems....

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....

On the Line: Professional Practice Solutions...

Author: Hughes, Gwen

Source: Journal of AHIMA

Publication Date: June 2000


Q: I work for a small physician practice. Until recently, physicians would take home patient records to dictate in the evening. Unfortunately, one of our physicians' cars was burglarized and 30 records were stolen. What should we do?
Q: Where I can access the Medicare Conditions of Part....

Setting the Standard in Assisted Living

Author:

Source: Journal of AHIMA

Publication Date: July 2000


Have you found yourself in the position of developing or reviewing health information and documentation policies for an assisted living facility? If so, you know that it is not easy to find resources or standards for this growing industry. However, both the Joint Commission on Accredit....

Answers to Confidentiality Concerns

Author: Hughes, Gwen

Source: In Confidence (newsletter) | AHIMA Q and A

Publication Date: July 02, 2000


Question: Who can authorize the disclosure of patient health information for a normally competent adult when that individual is unable to make informed decisions for himself?
Answer: The individual authorized to consent to the release of patient health information on behalf of a critica....

You've Got Inappropriate Mail

Author: Planchon, Don

Source: In Confidence (newsletter)

Publication Date: July 02, 2000


The use of e-mail and Internet access as a communication and research tool is now of strategic importance to both healthcare providers and consumers worldwide. However, use, or rather misuse, of these communication tools has introduced a host of security and legal threats uncontrolled by trad....

Internal Audit Model for Information Security

Author: Mead, Kevin

Source: In Confidence (newsletter)

Publication Date: July 02, 2000


Internal auditors are found within many organizations, and have traditionally concerned themselves with the protection of assets. In the past, this manifested itself by the placing of asset tags on furniture and equipment and verifying the presence of the asset each year. Recently, however, i....

Groups Offer E-health Ethics Smorgasboard

Author: Asmonga, Donald D.

Source: Journal of AHIMA

Publication Date: July 2000


E-health experts nationally are hard at work developing guidelines for this rapidly growing industry. Recently, three sets of guidelines were issued—by an advisory committee to the Federal Trade Commission, by the Internet Healthcare Coalition (IHC), and by a group of information....

Practice Solutions for Today

Author:

Source: Journal of AHIMA

Publication Date: July 2000


Editor's note: APCs, risk management, knowledge management...all of these are practice issues that will affect the way HIM professionals work in the future. But practice solutions exist right now in our day-to-day work environments as well. Here are a few successful practice sol....

Journal Q&A (7/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: July 02, 2000

Q: Should my HIM department accept a subpoena from another state?
A: According to AHIMA's Release and Disclosure: Guidelines Regarding Maintenance and Disclosure of Health Information, "state statutes define the power to issue subpoenas and that power varies from state to stat....

Journal Q&A (7/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: July 02, 2000

Q: Where I can find sample policies and procedures for confidentiality, security, and disclosure of patient health information?
A: The Computerized Patient Record Institute (CPRI) and 3Com Corporation have partnered to publish a CPRI toolkit at http://healthcare.3com.com/securitynet/h....

Documentation Errors Result in Medicare Overpayment

Author: Hammen, Cheryl

Source: Journal of AHIMA

Publication Date: July 2000



The objective of the Office of the Inspector General's (OIG) fiscal year 1999 audit was to determine whether medical fee-for-service claims complied with Medicare rules and regulations. The OIG examined claims for accurate documentation and coding, medical necessity, and to ensure that c....

Journal Q&A (7/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: July 02, 2000

Q: Where should informed consent forms for research and research-related access to patient records be filed?
A: As a general rule, records of informed consent or refusal to consent are filed in a patient's record. However, a notebook containing the following information can be valua....

Moving Gradually Toward a Paperless World

Author: Hagland, Mark

Source: Journal of AHIMA

Publication Date: September 2000


HIM professionals may not be totally ready for a paperless environment—but then again, neither is anyone else.
Linda Fischer Smith remembers well the days (after all, they were just a couple of years ago) when she and her colleagues in the health information management area at Kais....

Access Audit Trails: En Route to Security

Author: Halpert, Aviva M.

Source: Journal of AHIMA

Publication Date: September 2000


An electronic access audit trail can be an effective security tool if the right conditions are in place. In this article, learn how to ensure that your organization has the right technology, procedures, mechanisms, and plans to implement an audit trail.
Working with healthcare informatio....

Journal Q&A (9/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: September 02, 2000

Q: Is it legal to allow physicians within a group practice to authenticate records for each other?
A: This question comes up often in all practice settings, because it has become a common practice to allow physicians to sign for one another. Although regulations and accreditation stan....

Following the Electronic Trail

Author:

Source: Journal of AHIMA

Publication Date: September 2000


How can you protect patient information while maintaining immediate access for qualified employees? HIM professionals across the country are taking leadership roles in developing and managing audit trails for computerized health information. Here are a few of their success storie....

Clinton Signs E-signatures into Law

Author:

Source: Journal of AHIMA

Publication Date: September 2000


President Clinton signed the 'Electronic Signatures in Global and National Commerce' Act that provides electronic signatures the same weight as those in pen and ink. The provisions are currently limited to commercial transactions and become effective on October 1, 2000. When effective,....

Ten Steps to Selecting a Document Imaging Vendor

Author: Lofton, Sandra

Source: Journal of AHIMA

Publication Date: September 2000


On the road toward an electronic medical record, many organizations will need to evaluate and select document imaging systems. Because of the time and expense involved in these types of implementations, it is critical that the vendor selected be the right one for the organization. The process....

AHIMA Conference Probes E-health Questions

Author: Hughes, Gwen

Source: Journal of AHIMA

Publication Date: September 2000


Ten years ago, few of us envisioned the explosion of the Internet. Neither did we anticipate that the Internet would permeate our lives and change a myriad of daily routines.

Today, with every magazine, business, and think tank trying to envision what further ch....

E-Health and PKI Interoperability (Part 1)

Author: Barnett, David H.

Source: In Confidence (newsletter)

Publication Date: September 02, 2000


Part One of a Two-Part Article
Providing patient access to medical information and services over the Internet-often referred to as e-health-is an area of rapidly growing interest for many healthcare organizations today. One of the challenges for e-health is providing adequate and effecti....

Catching Up with PEPP

Author: Bryant, Gloryanne H.; Fletcher, Robin

Source: Journal of AHIMA

Publication Date: September 2000


A year ago, the Journal of AHIMA reported on the newly created Payment Error Prevention Program (PEPP), which went into effect in August 1999. What has happened since then?
Best Billing Practices

PEPP was created to reduce Medicare prospective payment system (PPS) ....

Where Are They Now? CPR Leaders Assess Their Progress

Author: Zender, Anne

Source: Journal of AHIMA

Publication Date: September 2000


Five years ago the first recipients of the Davies awards showed us successes of CPR systems across the country. Where are they now? This article catches up with these CPR leaders.
Is your job exactly the same as it was five years ago? For most HIM professionals, the answer....

Desperately Seeking the CPR in Long-Term Care

Author: Bolton, Zoe

Source: Journal of AHIMA

Publication Date: September 2000


With the explosion of technology in other areas of healthcare, long-term care specialists may find themselves feeling a bit left behind. Why isn't the computer-based patient record more prevalent in long-term care? While the industry is taking some first steps, there are still some sizeable ro....

Harnessing Technology for Success

Author: Jeffries, Jane

Source: Journal of AHIMA

Publication Date: September 2000


Kelly McLendon, RHIA, is working hard to make your job easier. As director of Chart Manager Domain at Eclipsys Corp., an information solutions company based in Delray Beach, FL, McLendon oversees HIM, clinical data management, and document management products that are designed to incre....

Journal Q&A (10/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: October 02, 2000

Q: What is the retention period for billing records, such as explanations of benefits, charge slips, invoices, etc.?
A: Most states have established a retention period for medical records, but many have not addressed other type of records like billing documents. The Medicare program m....

New Home Care PPS Brings Major Changes

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: October 2000


The home care industry will undergo a significant shift in reimbursement methodology when HCFA implements a new prospective payment system (PPS) for Medicare claims on October 1, 2000. Under the new system, a Medicare beneficiary receiving covered home care services will be reimbursed for a 6....

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