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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....

Journal Q&A (10/98)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: October 02, 1998


Q: Where can I find information about a system that will allow for the electronic transmission of Minimum Data Set (MDS) information?

A: One of the Health Care Financing Administration's (HCFA's) proposals relating to the MDS 2.0 resident assessment process requires lo....

Journal Q&A (4/98)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: April 02, 1998


Q: I'm looking for any information regarding the identification of duplicate medical record numbers, or any articles that might address the process of merging MPI systems. Can you help me?

A: See AHIMA's practice briefs on master patient indexes: "Master Patient (Pers....

Journal Q&A (11/04)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2004


Q: From a Washington State Community of Practice discussion thread: What should our facility do when we receive medical information burned to a CD in place of hard copies? Should we print copies? Should we send the CD back? If copies are printed, should the CD be maintained or destroyed?
....

Web FAQ

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: October 2002

How should we handle requests for birth information by adoptees?
Adoption is a statutory procedure governed entirely by state law.1 Although birth records are sealed, most states allow adoptees to get information about their birth parents but prohibit access to data that could be used to ident....

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 (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....

Journal Q&A (4/03)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: April 02, 2003

Q: An attorney recently told our facility that we need to retain records for at least 10 years to comply with the False Claims Act (FCA). Our state law only requires seven years. Which takes precedence?

A: The FCA (31 USC§3729–3733) applies to actions, jurisdiction, and procedu....

Year Ahead in HIM

Author: AHIMA Professional Practice Team

Source: Journal of AHIMA

Publication Date: January 2008


The healthcare industry enters 2008 with a score of hot topics related to health information management. Here are the issues to watch, picked by AHIMA’s professional practice and policy staff.
Presidential Election

Don Asmonga, MBA, director of government relatio....

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....

Journal Q&A (10/98)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: October 02, 1998


Q: I am currently serving on a team that is looking at re-engineering its patient cycle time (i.e., getting the patient in and out of the facility as quickly and efficiently as possible, without sacrificing patient/provider interaction). As we review our release of information processe....

Journal Q&A (11/02)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2002

Q: When should a change to scanned documents in an information system be identified as a late entry?

A: An entry is not considered "late" in a set time frame. Generally, an entry should be made as close to the event as possible. The more time that passes, the more suspicious and vulnerab....

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 ....

Journal Q&A (4/98)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: April 02, 1998


Q: I have a deposition scheduled for next week. The issue at hand is whether a preprinted manufacturer's instruction sheet on how to use a piece of medical equipment should be a part of the medical record. Our position is that it should not be included because it does not reflect ....

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....

Web FAQ

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: October 2002

Q: I've been approached about dictating hospital discharge summaries for a physician at our local hospital. Are there precautions or legalities that I should take into account?
A: Precautions are necessary for you and for the organization when considering participation in dictation of medical....

Journal Q&A (6/03)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: June 02, 2003

Q: What are a covered entity’s legal responsibilities when a former employee breaches confidentiality of information gained during his or her employment period?

A: Individual state laws would affect the outcome of litigation if charges were pressed through civil action. If the organ....

Journal Q&A (9/02)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: September 02, 2002


Q: A developmentally disabled adult was recently admitted to our hospital. The patient was accompanied by his older sister. The sister indicated her brother could not write but that he could draw an "X." Because the patient doesn't have a court-appointed guardian and his parents are deceased,....

Journal Q&A (4/98)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: April 02, 1998


Q: I have a practice question regarding sharing patient information with the state Department of Insurance. The ambulatory surgery center for which I work is having difficulty with several managed care companies that are not reimbursing our facility according to our contracts. It was....

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....

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 (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 (2/98)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: February 02, 1998


Q: I have been asked to head up a committee assigned the task of selecting the hardware and software applications that are to become the platform for our organization's computerized medical record (CPR). Our committee is composed of representatives of all the "end users" of the CPR. The vastne....

Journal Q&A (6/98)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: June 02, 1998


Q: What processes need to be developed to standardize data collection?


A: The list includes, but is not limited to, the following processes:
Appropriate education and training programs
Timely and appropriate communication of data definitions to those ....

Watson vs. Big Data

Author: AHIMA Staff

Source: Journal of AHIMA

Publication Date: July 2015


It is the matchup of the century—the towering hulk of healthcare’s Big Data versus the super computer known as Watson. Will Watson be able to take on this lumbering, untamed mass of information and whip it into submission?


One year ago, the Journal of AHIMA reported on the IBM su....

Frequently Asked Questions: Confidentiality

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: October 2002


How and Where Can I Obtain Copies of My State's Disclosure Laws?

My Physician Passed Away, and I'd Like to Know Where I Can Locate the Medical Records Originated at His/Her Office.

I Need to Locate Immunization Records for College and Am Unable to Locate My Physician. Wh....

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....

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....

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 (4/01)

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....

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....

Privacy or Convenience?

Author: AHIMA Staff

Source: Journal of AHIMA

Publication Date: February 2015


The tension between data privacy and consumers’ demand for their health information will become more strained in 2015, a new report predicts. As the number of privacy breaches in the healthcare sector has grown in recent years, so too has the desire of consumers to be one click away from....

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....

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....

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 (1/99)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: January 02, 1999


Q: I hear a lot of technical terms being used lately by information systems staff and I feel like I'm not speaking their "jargon." Could you clarify the meaning of some of these terms? Specifically, they are SQL, Java, TCP/IP, and IPX.

A: SQL stands for structured query language, whi....

Journal Q&A (6/98)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: June 02, 1998


Q: How do you "validate" a data collection instrument?

A: The purpose of validating the data collection instrument—including paper forms and computer screens—is to:
ensure that the data collected will support the intent of collecting the data....

Journal Q&A (6/02)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: June 02, 2002

Q: Is it true that the method for calculating the delinquent chart rate has changed and it is no longer necessary to carry a delinquent chart from month to month?
A: The method for calculating the delinquent chart rate has not changed. The Joint Commission confirmed that it considers a chart d....

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....

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