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Journal Q&A (10/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: October 02, 2000

Q: Can an emergency room exam serve as an inpatient history and physical?
A: It's important to understand the intent of the standards and regulations for hospitals and the practice standards for content of a history and physical (H&P) exam. The 2000 Joint Commission on Accreditation ....

XML Furthers CPR Goals

Author: Pothen, Daniel J.; Parmanto, Bambang

Source: Journal of AHIMA

Publication Date: October 2000


Many healthcare facilities have instituted Internet-based healthcare computing applications to better manage and communicate health information.1 Realizing the power and potential of the Internet, various health information system vendors are developing Web-based applications. The advent of th....

Speech Recognition Propels Transcription Revolution

Author: Schwager, Rob

Source: Journal of AHIMA

Publication Date: October 2000


Speech recognition technology continues to develop. Now, with additional enhancements, the latest models offer solutions for entire enterprises. The author rounds up the latest developments.
Most healthcare organizations and clinicians today have automated some portion of their health in....

Committee Works Toward Viable Data Sources

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: October 2000


The availability of patient health data continues to be a hotly debated topic on Capital Hill. Noting that the "lack of complete and comprehensive PMRI (patient medical record information) is a major constraint on the ability of our healthcare delivery system to enhance quality, i....

Journal Q&A (11/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2000

Q: Is it acceptable to use "canned" reports in transcription?
A: To the extent that outlines or phrases common to one or more providers in assessments and procedures are routine, they can and should be used to assist providers in documenting thoroughly and efficiently. How....

Next Generation of E/M Guidelines

Author: Hill, Emily

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2000


Few non-clinical issues have inspired as much discussion, revision, and anxiety as the evaluation and management (E/M) services and their accompanying documentation guidelines. E/M services have produced a cottage industry focused on ensuring that medical records contain necessary docu....

Security @ the Edge

Author: Boroditsky, Marc

Source: In Confidence (newsletter)

Publication Date: November 02, 2000


With the pending impact of the Health Insurance Portability and Accountability Act (HIPAA) requirements and the high hopes for fully automated e-medical informatics, healthcare information professionals must gain an appreciation for the edge of their networks. More than ever before, the edge....

Journal Q&A (11/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2000

Q: When a patient who was assaulted names her assailant, should the nurse or physician include the assailant's name in the medical record?
A: It is not uncommon for a healthcare provider to document in the record what the patient says when the information has some bearing on his or....

E-Health and PKI Interoperability (Part 2)

Author: Barnett, David H.

Source: In Confidence (newsletter)

Publication Date: November 02, 2000


Part Two of a Two-Part Article
In the previous issue, we discussed the need for common Certificate Policies in healthcare, such as the ASTM E31 Model Policy. Agreement on practices and policies, as specified in the Certificate Policy and Certification Practice Statements, can expedite in....

Journal Q&A (11/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2000

Q: How long is an authorization to release information valid?
A: For the most part, federal law does not specify a length of time for which authorizations to disclose information are valid. In Confidentiality of Alcohol and Drug Abuse Patient Records (42 CFR, Chapter I, Part 2), the....

Smart Cards May Make Security a Non-Issue

Author: Deike, Karen

Source: In Confidence (newsletter)

Publication Date: November 02, 2000


Smart cards have long held enormous potential for governments in managing healthcare information and delivering benefits to clients with more efficiency, less fraud, and greater customer satisfaction. But critical to gaining acceptance of the cards is the ability to assure clients that the in....

Envisioning the Personal Medical Record

Author: Odom-Wesley, Barbara

Source: Journal of AHIMA

Publication Date: November 2000


Increasingly, patients are becoming interested in maintaining their own personal health records. What should these records contain? A panel of experts offers their recommendations.
When was the last time you or a member of your family moved, changed doctors, or saw a specia....

AHIMA Releases E-health Tenets

Author:

Source: Journal of AHIMA

Publication Date: November 2000


In August 2000, AHIMA released a set of fundamental principles and operating tenets for placing consumer health records on the Internet. An excerpted version of these tenets follows. The document can be found in its entirety on AHIMA's Web site at www.ahima.org/hot.topics/ [web page no....

Journal Q&A (1/01)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: January 01, 2001

Q: What form must a subpoena duces tecum take in order to be valid?

A: A subpoena duces tecum commands a person to produce certain documents or evidence in court. The form that the subpoena must take to be valid is a matter of state law, but generally, a subpoena must contain the following....

Journal Q&A (1/01)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: January 01, 2001

Q: Can a healthcare facility release health information for marketing purposes?

A: There is a growing demand for and supply of health information for uses that are far removed from patient care or the payment process. It is imperative for a facility to establish a system of controls for id....

Journal Q&A (1/01)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: January 01, 2001

Q: What is the difference between confidential and nonconfidential health information?

A: Health information can be classified into two categories: confidential and nonconfidential. Confidential information is obtained during the course of a confidential relationship between a patient and....

Quick Take on Clearinghouses

Author: McLaughlin, Mark

Source: Journal of AHIMA

Publication Date: January 2001




HIPAA's provisions have brought healthcare clearinghouses into the spotlight. What is a clearinghouse, and how is its role affected by the new regulations? This article answers these questions.

A clearinghouse is typically used to collect, validate, and distribute insurance c....

Is Wireless Technology at Hand for Healthcare?

Author: Smith, Cheryl M.

Source: Journal of AHIMA

Publication Date: January 2001


It wasn’t so long ago that HIM professionals witnessed the introduction and use of computers to assist in performing everyday functions in an HIM department. The computerization of the master patient index moved us from typing patient demographic data and filing individual patient index cards....

Information Security: It Takes a Community

Author: Hjort, Beth M.

Source: Journal of AHIMA

Publication Date: January 2001


The Health Insurance Portability and Accountability Act of 1996 (HIPAA) reinforces what HIM professionals have known for a long time: security training is a prudent and valuable mission for an organization to support. Besides the obvious need for compliance with this new federal mandate, it’s....

Final Rule for Standards for Privacy of Individually Identifiable Health Information

Author: AHIMA Policy and Government Relations Team

Source: AHIMA Advocacy and Policy | AHIMA regulation analysis

Publication Date: January 02, 2001

Notes

Readers will notice that some word such as "healthcare" may be written in more than one way in this analysis. Style guides often require the term "healthcare" be stated as such, however, the federal government uses the term as "health care." In this document we will be using the te....

NCVHS on Signature Standards: Not Yet

Author:

Source: Journal of AHIMA

Publication Date: January 2001


Government subcommittee hearings on the development of electronic signatures ended inconclusively this fall, with requests for more input and a sense that the necessary technology may not have evolved.

Following the Health Insurance Portability and Accountability Act's (HIPAA)....

On the Line: Professional Practice Solutions

Author: Smith, Cheryl M.

Source: Journal of AHIMA

Publication Date: January 2001


Q: What is the difference between confidential and nonconfidential health information?

Q: Can a healthcare facility release health information for marketing purposes?

Q: What form must a subpoena duces tecum take in order to be valid?

Cheryl Smith is an AHIMA practice....

Knowledge Management: Finding the Golden Nuggets

Author: Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: January 2001


We live in the so-called Information Age, but we should actually refer to it as the Data Age. As a nation, we are data rich and information poor.

The dilemma of holding large amounts of valuable data but little useful information is not unique to healthcare. The inability....

New Expedition Begins: Privacy Under HIPAA

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: February 2001




While all regulations under the Health Insurance Portability and Accountability Act (HIPAA) directly affect how we manage health information, the privacy regulations are central for HIM professionals. It has always been our privilege to serve as patient advocates for information priv....

New Privacy Officer's Game Plan

Author: Dennis, Jill Callahan

Source: Journal of AHIMA

Publication Date: February 2001




The HIPAA-mandated privacy officer role offers a new opportunity for HIM professionals. What skills are required, and what needs to be done first? This article answers these questions.
As healthcare organizations roll out their plans for HIPAA implementation, many HIM profession....

Is PKI the Solution to HIPAA Security?

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: February 2001




Public key infrastructure (PKI) has been called the only technology currently available that will comply with the HIPAA proposed security rules. If you have heard of PKI but have yet to understand it, keep reading. This article will give you a nuts-and-bolts look at the technology a....

On the Line: Professional Practice Solutions

Author: Smith, Cheryl M.

Source: Journal of AHIMA

Publication Date: February 2001




Q: Where can I find information on the interpretation of Joint Commission on Accreditation of Healthcare Organization standards?

Q: How does the Health Insurance Portability and Accountability Act of 1996 (HIPAA) define health information in the final rule for healthcare elec....

Journal Q&A (2/01)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: February 02, 2001

Q: What are data sets?

A: Data sets support and encourage the uniform collection and reporting of data. They have been developed for different healthcare settings and are used to categorize patient data. Data sets are intended to describe significant minimal data about patients, residents....

Using Physician Profiling to Improve Documentation

Author: Hammen, Cheryl

Source: Journal of AHIMA

Publication Date: March 2001




In today’s competitive market, physician profiling has become a way to provide consumers with a "snapshot" of a physician. It is also used in determining physician participation in various managed care contracts through identification of variations in physician practice pa....

From DNA to Data Privacy

Author: Fuller, Barbara P.; Jeffries, Jane

Source: Journal of AHIMA

Publication Date: March 2001




Genetic research is revolutionizing healthcare by predicting diseases and revealing cures. At the same time, the information presents new challenges to HIM professionals charged with keeping this vital data from the wrong hands. Here's a look at the role genetic information is playin....

Caught in the Camera's Eye: Filming and Patient's Consent

Author: Joint Commission on Accreditation of Healthcare Organizations

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

Publication Date: March 02, 2001


Q: Can staff of a healthcare organization, or their designated agent, film or videotape patient care activities in the Emergency Department? Does the staff have to get a patient’s consent to film or videotape their care while it is being provided?
A: Yes, to both questions. It is appropri....

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....

On the Line: Professional Practice Solutions

Author: Smith, Cheryl M.

Source: Journal of AHIMA

Publication Date: April 2001




Q: What are the documentation requirements for the content of a discharge summary?

Q: Does the Joint Commission still conduct random unannounced surveys?
Cheryl Smith (cheryl.smith@ahima.org) is an HIM practice manager.Article citation:
Smith, Cheryl M. "On the....

AMA Issues Guidelines for Patient Privacy

Author: Jeffries, Jane

Source: Journal of AHIMA

Publication Date: April 2001


Prominent healthcare experts unveiled ethical guidelines calling on all participants in the healthcare system--from physicians, hospitals, and health plans to employee benefit managers, unions, and others--to rigorously protect the confidentiality of any medical records entrusted to them.
....

Winning Joint Commission Jeopardy: Tips for Success

Author: Brow, Julie A.

Source: Journal of AHIMA

Publication Date: April 2001




Organization, preparedness, and quality are three familiar words to those managing hospital and clinic health information. At no time is it more important to be organized, prepared, and quality-minded than when surveyors from the Joint Commission on Accreditation of Healthcare Organi....

Journal Q&A (5/01)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: May 02, 2001

Q: Does the new HIPAA privacy rule require hospitals to obtain patient consent prior to sending copies of dictated reports and test results to the patient's physician?

A: Unless the HIPAA privacy rule published on December 28, 2000 (45 CFR Parts 160 through 164) is modified by the Bush ad....

Journal Q&A (5/01)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: May 02, 2001

Q: Have the American Society for Testing and Materials (ASTM) standards relative to medical transcription been finalized?

A: ASTM recently published the Standard Guide for Identification and Establishment of a Quality Assurance Program for Medical Transcription. This five-page guide was....

Data Transmission: A World of Possibilities

Author: Smith, Deborah A.

Source: Journal of AHIMA

Publication Date: May 2001




In a landscape of regulation and consolidation, healthcare providers must find new, cost-effective ways to communicate sensitive data with partners. Observations, lab results, and admission-discharge-transfer data must be shared accurately, confidentially, and in a timely manner with....

Trends to Watch in Home Health Compliance

Author: Abraham, Prinny

Source: Journal of AHIMA

Publication Date: May 2001




The implementation of the Home Health Prospective Payment System (PPS) on October 1, 2001, has presented some unique compliance risks for HIM and billing managers. This article will briefly describe some of the compliance-related issues on the OIG's agenda that are of interest to HIM....

Release of Information: the Basics

Author: Yaggie, Elaine

Source: Journal of AHIMA

Publication Date: May 2001




Whether you're new to the HIM profession or a long-time expert, release of information presents perennial challenges-especially in light of HIPAA. This article brings you the basics and the latest updates.
Release of health information has been a hot topic for years. Today, more....

Compliance: A Critical Yet Costly Commitment

Author: Roach, Daniel R.

Source: Journal of AHIMA

Publication Date: May 2001




In the 1970s, the defense budget consumed the largest share of the federal budget. Concerns about both the size and efficiency of the defense bureaucracy triggered a massive crackdown on federal contractors who had either intentionally or inadvertently failed to follow the Department....

Sample Consent Agreement

Author: AHIMA Staff

Source: AHIMA sample form

Publication Date: May 02, 2001




Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations


I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test....

On the Line: Professional Practice Solutions

Author: Hughes, Gwen

Source: Journal of AHIMA

Publication Date: May 2001




Q: I understand that inexpensive password recovery software can allow an unauthorized user to recover or crack someone else's password. If passwords are that easy to crack, are they worthwhile?



Q: Does the new HIPAA privacy rule require hospitals to obtain patient....

Radiology Moves to the CPR

Author: Hughes, Gwen

Source: Journal of AHIMA

Publication Date: June 2001




As HIM professionals move toward paperless health records, our colleagues in radiology are making the transition to filmless records.

Those in predominantly paper-based ambulatory care environments know how challenging it is to make sure each patient record contains all th....

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....

AMA Ethical Force Initiative Announced

Author: Halpert, Aviva M.

Source: In Confidence (newsletter)

Publication Date: July 02, 2001


While the healthcare establishment waited with bated breath for the publication of the elusive HIPAA privacy regulations in December 2000, the American Medical Association (AMA) published one of the first installments of its Ethical Force Program (E-Force) privacy module.
The Ethical Fo....

Psychotherapy Notes under HIPAA

Author: Dougherty, Michelle

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

Publication Date: July 02, 2001


Q: I work in a non-psychiatric facility covered by HIPAA. On occasion, a patient may receive a psychological evaluation and possibly treatment for a short period of time. Our medical record does not include a copy of the psychotherapist’s “notes,” but a report that summarizes the psychologist....

HIPAA's New Mandate for Psychotherapy Notes

Author: Rhodes, Harry B.

Source: Behavioral Health

Publication Date: July 02, 2001


The new HIPAA privacy final rule mandate that affords a higher level of privacy restriction to psychotherapy notes is creating a fair amount of confusion for healthcare providers. Restricted access to mental health records should not be something new to health information management profession....

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