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Sorting out Advance Directives

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: January 2011


Important differences exist in advance directives. Only some grant access to another person's medical records, and that can change with time.

After 50 years of marriage, Rosa Taylor-Payne noticed even the slightest change in her husband, Marvell Payne. So she started to worry when he....

EHRs as the Business and Legal Records of Healthcare Organizations. Appendix A: Issues in Electronic Health Record Management (2010 update)

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: November 2010


Electronic health record management (EHRM) is the process by which electronic (e.g., digital) health records are created or received and preserved for legal or business purposes. EHRM requires decision making throughout the EHR’s life cycle-through the processing, distribution, maintenanc....

EHRs as the Business and Legal Records of Healthcare Organizations. Appendix B: Checklist for Transition to the EHR (2010 update)

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: November 2010


Editor's note: This checklist combines and updates the October 2004 practice brief appendix "The Strategic Importance of Electronic Health Records Management: Checklist for Transition to the EHR" and the June 2005 practice brief "A Checklist for Assessing HIM Department Readiness and Planning f....

Migrating from Paper to EHRs in Physician Practices. Appendix A: Historical Medical Record/Chart Abstraction Checklist—Primary Care

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: November 2010


This checklist can help physician practices migrate all the appropriate data from an individual patient paper record into the EHR. Each record or data element should be expanded upon with descriptions based on the practice’s definitions, the location of the information in the paper chart,....

Streamlining Patient and Physician Communication: IT Systems and Internet Offer Paths for Effective Communication for Patient Care

Author: Warner, Diana

Source: Journal of AHIMA

Publication Date: November 2010


Many organizations still struggle with ongoing and timely clinical communication among physicians and between physicians and their patients. Physician-to-physician communication for ongoing patient care is especially complex. It requires identifying all physicians involved in the care of a pat....

Migrating from Paper to EHRs in Physician Practices - Retired

Author: AHIMA

Source: AHIMA practice brief

Publication Date: November 2010


A successful transition from paper-based charts to electronic health records (EHRs) in the physician practice or clinic requires careful coordination of many moving parts. A myriad of challenging and complex decisions must be made, ranging from selection and implementation to training and maint....

CPOE Lessons Learned

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: October 2010


Hospitals and healthcare providers acknowledge that computerized physician order entry (CPOE) systems effectively address patient safety issues such as medication errors and document legibility. Built-in clinical decision support alerts can help identify drug-to-drug interactions or dosage err....

Integrating Medical and Dental Records: A New Frontier in Health Information Management

Author: Rudman, William J.; Hart-Hester, Susan; Jones, Warren A.; Caputo, Nadine; Madison, Mary

Source: Journal of AHIMA

Publication Date: October 2010


Integrating records of systemic and oral health would improve patient care. It would also open up a new frontier in health information management.

A fully integrated patient record and care model for both systemic health (medical) and oral health (dental) is needed for health informa....

D.I.Y. R.O.I: Do It Yourself Release of Information

Author: Haas, Mark

Source: AHIMA Convention

Publication Date: September 29, 2010


BACKGROUND


The Massachusetts General Hospital (MGH) has seen a precipitous increase in the volume of release of information requests processed over the past five years. The Health Information Management department has struggled mightily with trying to handle this steady increas....

HITECH Security – A Practical Approach

Author: Rudloff, Rob

Source: AHIMA Convention

Publication Date: September 28, 2010


Background


HITECH has introduced new security requirements around HIPAA including new breach requirements and associated penalties. This paper addresses the information security and privacy requirements and provides practical solutions to address them. Many organizations already....

Success with Speech Recognition

Author: Clawson, Cathy

Source: AHIMA Convention

Publication Date: September 28, 2010


Introduction: Since Mountain States Health Alliance implemented the Dolbey Speech Recognition platform in October 2007; gains in productivity, decrease in outsourcing, and financial savings have confirmed the successful implementation of this technology.
Background/History: Mountain Sta....

Data Security Compliance in IT Asset Disposition

Author: Adam, Chris

Source: AHIMA Convention

Publication Date: September 28, 2010


Introduction

Stories about the theft of confidential data have made headlines all too frequently over the past few years. This reality is forcing some businesses to face up to an inconvenient truth: Many organizations have no reliable procedures to ensure that the computers and rel....

Role of Data Analysis in Revenue Cycle Improvement

Author: White, Susan E

Source: AHIMA Convention

Publication Date: September 27, 2010

Introduction

Data analysis techniques are becoming increasingly important for HIM professionals. The application of relatively simple and straightforward data analytics can identify significant opportunities for improvement in the revenue cycle. Traditional chart audits can be enhanced b....

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