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Common E/M Documentation Issues

Author: Udell, Curtis

Source: Brief Encounter

Publication Date: July 02, 2001


One of the constant challenges facing managers today is evaluating physician documentation and then helping their physicians to improve the content of their patient notes, particularly for evaluation and management (E/M) services.

While physicians may have unique style or flair to t....

Navigating the Physician Services Maze

Author: Skurka, Margaret A.

Source: Journal of AHIMA

Publication Date: July 2001


As HIM professionals know, accurate and complete documentation is critical for providing care and supporting reimbursement. This is particularly true-and yet particularly problematic-in the area of E/M coding. Medical practices report and are paid for their services using E/M coding, yet there....

Testimony on Behalf of The American Health Information Management Association (AHIMA) to the Privacy and Confidentiality Subcommittee of the National Committee of Vital and Health Statistics (NCVHS)

Author: Rode, Dan

Source: AHIMA testimony and comments

Publication Date: August 22, 2001

August 22, 2001


Mr. Rothstein, members of the Privacy and Confidentiality Subcommittee, ladies and gentlemen - good morning!

I am Dan Rode, vice president for the AHIMA. On behalf of the Association, its more than 40,000 members, and myself, thank you for the opportunity....

Journal Q&A (9/01)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: September 02, 2001

Q: My facility's records contain a variety of psychiatric documentation including therapists' notes from their treatment sessions with patients. How can I determine what requires special protection under HIPAA? Do I need to separate some of the documentation from the medical record? Currently all p....

Securing Your IT Environment from the Inside Out

Author: Bakman, Alex

Source: In Confidence (newsletter)

Publication Date: September 02, 2001


IT security has been gaining in importance throughout the history of digital data, and industries are gradually regulating themselves or facing governmental compliance standards. The healthcare industry possesses some of the most critical data and network technology in that lives and patient....

Getting More Personal

Author: Hagland, Mark

Source: Journal of AHIMA

Publication Date: September 2001


Personal health records online are flourishing, but every setup is different. Here’s a look at how organizations and patients are managing personal health records.
Last spring Eugene Ernest “Ernie” Somera found out that he had elevated blood sugars, a sign that he was slid....

Informatics in Managed Care: HIM Adds Value to Data

Author: Stratton, Scott D.

Source: Journal of AHIMA

Publication Date: September 2001

The third installment of the Journal of AHIMA’s special series on managed care focuses on informatics-methods that add value to data, turning it into useful information. How do informatics and managed care fit together, and what is HIM’s role in this picture?

The HIM professional’s knowl....

Teaching Physician Guidelines

Author: Graff, Jean Stevens

Source: Brief Encounter

Publication Date: September 02, 2001


Working in an orthopedic clinic, I understand the great need for my newly created position. I am employed at a teaching hospital as a medical record auditor charged with the task of educating physicians on the art of coding and documentation. My job is to ensure compliance with the Medicare ma....

Journal Q&A (9/01)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: September 02, 2001

Q: I work in a home care agency and am developing a procedure on correcting errors on OASIS to comply with the Centers for Medicare and Medicaid Services' (CMS, formerly HCFA) new correction policy. Is it necessary to make a separate entry in the medical record? Our agency would like to make the co....

On the Line: Professional Practice Solutions

Author: Hjort, Beth M.

Source: Journal of AHIMA

Publication Date: October 2001




Q: The nursing department has asked the HIM department for assistance in creating an organized process for thinning inpatient charts. Is there a standardized method that I could suggest?



Q: Are there standards for establishing chart document order either during or....

Managing Exceptions to HIPAA's Patient Access Rule

Author: Hughes, Gwen

Source: Journal of AHIMA

Publication Date: October 2001




The HIPAA final privacy rule requires that covered entities allow individuals to access the medical and billing records maintained about them. However, the rule describes 10 exceptions. Accordingly, healthcare providers must establish a way to identify the medical and billing records....

NCVHS Groups Explore CPR, Privacy Rule Possibilities

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: October 2001




HIPAA's fifth anniversary was marked by meetings of two key subcommittees of the National Committee on Vital and Health Statistics (NCVHS): the standards (transactions) and security subcommittee and the privacy and confidentiality subcommittee. At the security subcommittee, experts fr....

Early Word on HIPAA Claims Attachments

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: October 2001


If we could look into a crystal ball and see into the future, it would be much easier to prepare for HIPAA, particularly the electronic transaction standards. Because of the rarity of crystal balls these days, we must rely on other predictors at our disposal, such as the white paper issued by t....

Journal Q&A (10/01)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: October 02, 2001


Q: The nursing department has asked the HIM department for assistance in creating an organized process for thinning inpatient charts. Is there a standardized method that I could suggest?

A: HIM professionals are often asked for guidance in determining chart thinning practices, setting....

Award-winning Approach to HIM

Author: Jeffries, Jane

Source: Journal of AHIMA

Publication Date: October 2001




Imagine working on a project that takes more than 10 years to complete. Sounds a little depressing, right? But what if each step in that project improved patient care, made physicians' lives a little easier, and increased security for patient information? What if your efforts led to a....

Journal Q&A (10/01)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: October 02, 2001


Q: Are there standards for establishing chart document order either during or after hospitalization?

A: Similar to chart thinning, there are no universal standards for chart order. Healthcare organizations are encouraged to develop a standardized arrangement that works well in offerin....

Document Imaging: Lessons Learned

Author: Myjer, D'Arcy; Madamba, Roderick

Source: AHIMA Convention

Publication Date: October 10, 2001



Introduction


As all of us realize, healthcare is slowly moving toward an electronic medical record environment. The reasons today are just as valid as they were 20 years ago: immediate access to the patient record, less time charting and more time caring for patients, better....

Preparing Your Department and the Records for the EMR

Author: Bowers, Donna

Source: AHIMA Convention

Publication Date: October 10, 2001




Introduction

The electronic medical record functionality available in the healthcare industry represents one of the most important advances in HIM industry technology. The considerable advantages of an electronic medical record and computer-based patient record include the....

Statewide Data Systems: Entering a New Era

Author: Love, Denise

Source: Journal of AHIMA

Publication Date: November 2001




Statewide data systems are the mainstay of many state and federal data systems and of many quality assessment, research, and policy initiatives. The author gives an overview of the different kinds of systems available and looks at opportunities for growth in the future, as well as for....

Driving Quality through Data Management: Three Stories

Author:

Source: Journal of AHIMA

Publication Date: November 2001


In the past few issues, the Journal of AHIMA has presented a special series on opportunities for HIM in the managed care arena. In the final article of the series, we focus on quality improvement (QI) initiatives.

HIM professionals are vitally important to QI initiatives, particularly....

What's New in Clinical Data Repositories?

Author: Soule, Dan

Source: Journal of AHIMA

Publication Date: November 2001




Clinical data repository (CDR) technology may have dropped off your radar screen,  but new developments are giving a second generation of CDRs a renewed role. This article offers an overview of the latest developments and a look at how CDRs can benefit healthcare.


....

Journal Q&A (11/01)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: November 02, 2001


Q: Where can I find the updated data elements and data definitions for the Uniform Hospital Discharge Data Set (UHDDS)?

A: At this time, the 1986 UHDDS data elements and definitions are not available electronically though the information is considered to be in the public domain. The fi....

On the Line: Professional Practice Solutions

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: November 2001


Q: Where can I find the updated data elements and data definitions for the Uniform Hospital Discharge Data Set (UHDDS)?

Q: Where can I find an easy-to-use glossary for terms in the HIPAA regulations?

Michelle Dougherty (michelle.dougherty@ahima.org) is an HIM practice manager....

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.
....

Are You Vulnerable to Hackers?

Author: Sardinas, Joseph L. Jr.; Muldoon, Jeannine D.

Source: Journal of AHIMA

Publication Date: November 2001


You might think computer hackers’ activities are restricted to viruses and hoaxes. Unfortunately, their repertoire is far larger, which puts your facility’s computer system-and patient privacy-at risk. This article provides a look at how hackers work and the best ways to protect your systems.....

Florida Cancer Data System Turns Data Into Information

Author: Zernich, Gordon

Source: Journal of AHIMA

Publication Date: November 2001


The enactment of the Cancer Registries Amendment Act in 1992 and the passage of similar state laws require healthcare facilities and state and national registries to gather information on certain diseases from patient medical records. The information is also used to identify geographic "ho....

Managing Complaints in the Modern Hospital

Author: Sobel, David A.

Source: Journal of AHIMA

Publication Date: November 2001


Pam, a critical care nurse at a teaching hospital, logged into her e-mail account and opened the following message: “Just thought you’d like to know that Carol had 104 degrees of fever with chills and she is getting blood cultures, blood work, x-rays, agglutinins for legionella, and influenza.....

Dilemma of Patient Health Record Security

Author: Demster, Barbara

Source: In Confidence (newsletter)

Publication Date: January 02, 2002


E-health privacy and security can be confusing and overwhelming issues when one is new to the world of technology and the Internet.
Many perceive the Internet as a clearly defined entity in a universe called cyberspace.We see “e-health” defined as Internet-related healthcare activities,....

Journal Q&A (1/02)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: January 02, 2002


Q: A couple were on vacation in my city when the husband suddenly became ill and died in our facility. The wife requested copies of the record to take home with her. She had listed herself as next of kin. Was it correct to give her a copy of the record?


A: The answer to this qu....

Journal Q&A (1/02)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: January 02, 2002


Q: Our fiscal intermediary (FI) has recently informed us that we are obligated to notify them whenever an attorney requests a record of a Medicare patient. Is that true?


A: It appears to be true. The Medicare Intermediary Manual states:


Provider Receives Reques....

Use of Language-Interpreter Consent Form

Author: Gore, Glennda

Source: AHIMA Foundation

Publication Date: January 08, 2002



In an effort to comply with the upcoming HIPAA confidentiality requirements, McAlester Regional Health Center has begun to review all policies and procedures concerning patient confidentiality and data security. During this process, the use of language interpreters was identified as one a....

Dilemma of Psychotherapy Notes and HIPAA

Author: Nicholson, Ruby E.

Source: Journal of AHIMA

Publication Date: February 2002


For HIM professionals in behavioral health settings, the HIPAA privacy regulations pose a downright dilemma. Here’s why.


The privacy rule defines psychotherapy notes as:


Notes recorded in any medium by a mental health professional documenting or analyzing....

Handling a Security Breach: Lessons Learned

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: February 2002


Consider this: your facility just received a call from a reporter asking for a comment. He’s writing an article on a hacker who accessed your network, downloaded patient medical information, and distributed copies to the press.


If your facility experienced a security inci....

Countdown to Compliance: Privacy

Author: Ingram-Muhammad, Sybil

Source: Journal of AHIMA

Publication Date: February 2002


How far along the road to compliance with the HIPAA privacy regulation is your organization? This article tells you the steps you should be taking to get in compliance by the April 2003 deadline.

It is February 2002—14 months before your organization has to be compliant with th....

Journal Q&A (3/02)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: March 02, 2002

Q: We have a transcriptionist who picks up tapes, transcribes them off-site, and returns them each day. Is this practice legal under HIPAA?


A: The HIPAA privacy rule does not prohibit the use of tapes for dictation, nor the use of an outside transcription vendor. The privacy rule do....

Journal Q&A (3/02)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: March 02, 2002


Q: Is it important to get a new do not resuscitate (DNR) order when a patient is transferred with a DNR order from another facility?


A: It would be best to obtain a new DNR order. The patient or legal representative may have changed his or her mind or assume that your facility....

Journal Q&A (3/02)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: March 02, 2002

Q: My facility administers flu vaccines to patients without requiring a scheduled appointment. Must the vaccine consents obtained be filed in the individual’s health record and how long should we retain them?


A: Consent forms are indeed part of an individual’s legal health....

Value of Digital Signatures

Author: Barnett, David H.

Source: In Confidence (newsletter)

Publication Date: March 02, 2002


This is the first article in a two-part series. Look for part two in the April issue of In Confidence.
As we move into the area of electronic health records, one problem is replacing written signatures with their electronic equivalent. Typing my name at the bottom of this document could....

Journal Q&A (3/02)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: March 02, 2002

Q: Does the individual to whom a patient has granted durable power of attorney for financial matters have the right to access and authorize use or disclosure of the patient’s protected health information (PHI) under HIPAA?


A: An individual granted durable power of attorney for....

Quality at the Core

Author: Zender, Anne

Source: Journal of AHIMA

Publication Date: March 2002


Is your hospital getting ready for the Joint Commission’s core measures project? Some hospitals are already transmitting the necessary data as part of the pilot project. Here’s how they are handling the challenges and deriving benefits.
If you’re an HIM director, you prob....

Web-based System Improves Access

Author: Burrington-Brown, Jill

Source: Journal of AHIMA

Publication Date: March 2002


Does the idea of the paper medical record dying a natural death due to irrelevancy sound intriguing? This is the future of the paper medical record, according to Bruce Elkington, chief information officer of Overlake Hospital Medical Center in Bellevue, WA. The strategy at Overlake has been to....

Mergers and Acquisitions: They Could Happen to You

Author: Pinder, Ray

Source: Journal of AHIMA

Publication Date: March 2002


If you have never been involved in a merger or acquisition, be aware that it could happen to you. There is important information you need to know, including what steps to take to process medical records according to your state regulations, accreditation standards, payer requirements, condition....

Key to Using Digital Certificates

Author: Barnett, David H.

Source: In Confidence (newsletter)

Publication Date: April 02, 2002


This is the second article in a two-part series.
Background

For over 2,000 years, in all recorded histories and for all civilizations, sending secret messages required that both the sender and receiver share a common secret key. The key that decrypted a message was the same a....

Megatrends Promise Transcription Changes

Author: Zernich, Gordon; DeVitt, Bill

Source: Journal of AHIMA

Publication Date: April 2002


HIM directors who are staying ahead of the curve can understand the effect that several megatrends will have on the transcription industry. These trends include increased volumes, use of third-party transcription services, new technology and increased expectations, standardized billing, and sh....

Journal Q&A (4/02)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: April 02, 2002

Q: My facility is bringing back the release of information function. We are considering a flat fee of $15 per disclosure. Does this seem reasonable?


A: Prior to establishing a new fee schedule for disclosing health information, HIM professionals should research federal and state la....

Journal Q&A (4/02)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: April 02, 2002

Q: I have been asked to identify all of my organization’s business associates so we can update their contracts prior to the April 2003 HIPAA privacy rule compliance date. Unfortunately, existing contracts are not maintained in one place. How should I tackle this project?


A: At....

Changing Face of Public Health Reporting

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: April 2002


In recent months, anthrax outbreaks and concern over bioterrorism threats have created a greater need for the US to have a system to monitor and report public health information in a timely manner. The Centers for Disease Control and Prevention (CDC) are developing standards for a new approach....

Power of PKI in Healthcare

Author: Lovorn, Jan

Source: In Confidence (newsletter)

Publication Date: April 02, 2002


Increasingly, segregated healthcare players have adopted labor-saving technology to become or stay competitive in the healthcare marketplace. However, the real efficiencies will be found in a universal effort to integrate these independent delivery systems across an organization or communities....

Journal Q&A (4/02)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: April 02, 2002

Q: The physician practice I work for often receives photocopies of health information sent in anticipation of a new patient consultation or appointment. If the individual never presents to the practice, how long must our practice retain this health information?


A: While healthcare....

Get Serious About Paper Record Destruction

Author: Mead, Kevin

Source: Journal of AHIMA

Publication Date: May 2002


How serious are you about your document destruction processes? There are steps that you can take that ensure protection from liability and embarrassment after the records are tagged for disposal. Merely saying “we shred our old records” and “we have a certificate of destruction&....

Journal Q&A (5/02)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: May 02, 2002

Q: In light of HIPAA restrictions on protected health information, I’m concerned about our HIM department’s practice of accepting HIM students for professional practice experience. What should be considered in deciding whether to continue this practice?


A: HIPAA’s pr....

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