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Journal Q&A (7/03)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: July 02, 2003

Q: When is a new history and physical (H&P) needed when moving a patient between an acute care bed to a swing bed?

A: The key to determining when an H&P is needed is to find out how the swing bed is being used and the regulations that apply. Section 1883 of the Social Security Ac....

Documentation Coordinators Put it All Together

Author: Squazzo, Jessica

Source: Journal of AHIMA

Publication Date: July 2003


There are very few medical records departments that have a position as unique as mine,” says Karen Santoro, documentation coordinator at Banner Thunderbird Medical Center in Glendale, AZ. The fact that many organizations don’t have a documentation coordinator position on their roster....

Saving Time: A Physician's Perspective

Author: Pezzulich, Robert

Source: Journal of AHIMA

Publication Date: July 2003


Thanks to the benefits technology brings to quality healthcare and operational efficiency, most healthcare organizations are finding themselves progressing deeper into the electronic environment. Besides the obvious technological challenges, this evolution involves the human factor, including....

Stealth Software Deters PHI Theft

Author: Kawles, Terrance L.

Source: Journal of AHIMA

Publication Date: July 2003


As the leading edge of digital portability advances, the protections afforded the “portability” portion of HIPAA become strained. Under the final security standards, covered entities (CEs) must establish procedures and mechanisms to protect the confidentiality, integrity, and availab....

Pneumonia [Documentation Suggestions]

Author: Health Care Excel

Source: External - used with permission

Publication Date: July 07, 2003

Describe clinical signs and symptoms (e.g., fever, chills, cough, dyspnea, tachypnea, crackles or rales, etc.).
Note radiological and laboratory findings - include rationale for disagreement with any findings (e.g., negative chest xray, culture, etc.).
Describe preadmission treatment tha....

Septicemia [Documentation Suggestions]

Author: Health Care Excel

Source: External - used with permission

Publication Date: July 07, 2003

Describe clinical signs and symptoms (e.g., hypoxemia, tachycardia, leukopenia, bradypnea, leukocytosis, etc.).
Identify causative organism, if known (e.g., pneumococcal, E. coli, aerobacter aerogenes, etc.).
List infection source, if known (e.g., UTI, pneumonia, postoperative wound, etc.....

Security and HIPAA: Protecting Your Operations

Author: Ruano, Michael

Source: In Confidence (newsletter)

Publication Date: August 02, 2003


Part six in a 10-part series.
This article is the sixth of a 10-part series that introduces the domains of information security and relates them to federal HIPAA regulations. The information security domain of operations security includes the topics of controls, protections, monitoring,....

New Tool Streamlines HIPAA Assessment Process

Author: Cohen, Kathleen

Source: In Confidence (newsletter)

Publication Date: August 02, 2003


How are you making sure that your organization is complying with the HIPAA privacy regulations? Many hospitals are doing HIPAA rounds with privacy officers, going from unit to unit to assess and document HIPAA compliance. But trying to make sense of the data collected during HIPAA rounds can....

Journal Q&A (9/03)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: September 02, 2003

Q: Under HIPAA, how should covered entities respond to requests from public health officials who state that they need protected health information (PHI) to carry out their duties?

A: The privacy rule recognizes that PHI may be needed to respond to threats to public health, including the....

HIM Professionals Key to Patient Safety

Author: Servais, Cheryl

Source: Journal of AHIMA

Publication Date: September 2003


In January 2003, the Joint Commission made 11 recommendations for patient safety. HIM professionals play critical and supporting roles in implementing these recommendations. This article will discuss some of the recommendations, with examples of their use in various aspects of an HIM departmen....

Are Ethics Guiding Your Workplace?

Author: Yokubaitis, Pamela R.

Source: Journal of AHIMA

Publication Date: September 2003



Sanctions under the HIPAA regulations mean serious financial consequences for healthcare professionals who release protected health information to others without following proper disclosure protocols. But HIM professionals should not be motivated by fear of financial consequences alone. Ou....

Consumer-based Records Create HIM Opportunity

Author: Friedman, Beth

Source: Journal of AHIMA

Publication Date: September 2003


The power of the Internet combined with our evolution toward e-HIM is driving HIM toward the next plateau—providers connecting with consumers on the Internet through consumer-based health information. This article will discuss the consumer-based health record and its place in the future o....

Online Records Serve Patients, Clinicians, and HIM

Author: Foster, Erica; Martin, Holly; Partin, Mary; Lockshaw, Jim; Fogelman, Adam; Folz-Murphy, Nancy; Harris, C Martin

Source: Journal of AHIMA

Publication Date: September 2003


Patients want online access to their health information but clinicians and HIM professionals don’t need any more work. The solution? An online medical record driven by the EHR. Here’s one organization’s success story.

If your own increasing Internet usage isn’t p....

AHIMA, Industry Groups Make Connections to Promote Health Records

Author: AHIMA

Source: AHIMA Advantage

Publication Date: September 2003


Are you ready for the e-HIM future? In the coming months, you'll be hearing a lot about AHIMA's e-HIM initiative. E-HIM stands for "electronic health information management" and looks ahead to the benefits and changes that will occur when the industry makes the transition from managing paper-ba....

Journal Q&A (9/03)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: September 02, 2003

Q: Does HIPAA prohibit physicians from using cell phones to dictate reports?

A: The privacy rule does not address the use of cell phones. Generally, cell phones transmit unencrypted information over insecure lines. These factors alone could be the basis for a policy prohibiting dictation....

Provider-Patient E-mail: With Benefits Come Risks

Author: Baker, Dixie B.

Source: Journal of AHIMA

Publication Date: September 2003


If you've ever played phone tag with your doctor, you can appreciate the benefits of e-mail. But for all its advantages, provider-patient e-mail is not without challenges. Here's how to protect your organization.
The majority of Americans now consider e-mail and instant messaging preferred....

Growing Influence

Author: Jeffries, Jane

Source: Journal of AHIMA

Publication Date: September 2003


Implementing an electronic health (EHR) record doesn’t happen overnight, Pamela Haines, RHIA, will tell you. In fact, it may take a few years. But Haines has made big progress in the five years since she started as the only HIM professional at Operation PAR, a multi-site behavioral healthc....

HIM Professionals Vital in Transition to e-HIM

Author:

Source: AHIMA Advantage

Publication Date: September 2003


Reach into the future and consider this scenario: You start work at 9 a.m. one day, but you don't hit the third floor elevator button for the HIM department…because it physically doesn't exist. There are no walls, no file rooms or shelving. Instead, you and other HIM colleagues are now fully in....

Long-term Acute Care: the Effect of PPS

Author: Smith, Pam

Source: Journal of AHIMA

Publication Date: October 2003


Just when I thought I’d seen and done it all in the HIM world, a new opportunity for coders appeared in long-term acute care hospitals (LTCHs). HIM professionals have been employed in LTCHs since the inception of long-term acute care, but the change from cost-based reimbursement to inclus....

Implementing Electronic Signatures - Retired

Author: AHIMA Task Force

Source: AHIMA practice brief

Publication Date: October 2003

Implementing Electronic Signatures (AHIMA Practice Brief)
Editor's note: The following information supplants information contained in the practice brief "Electronic Signatures (Updated)" published in the October 1998 Journal of AHIMA.
Electronic health records may provide the ability to....

Introduction and Table of Contents

Author: AHIMA Task Force

Source: AHIMA report

Publication Date: October 20, 2003

Introduction


In early 2003, the American Health Information Management Association (AHIMA) appointed a task force of experts to develop a vision of the e-HIM future. The task force developed the following vision of the future of health information: "The future state of health inform....

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