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Problem List Guidance in the EHR

Author: AHIMA Work Group

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: September 2011


Problem lists facilitate continuity of patient care by providing a comprehensive and accessible list of patient problems in one place. Problem lists used within health records are a list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifyi....

Clinical Terminology and Clinical Classification Systems: A Critique Using AHIMA’s Data Quality Management Model

Author: Alakrawi, Zahraa M

Source: Perspectives in Health Information Management

Publication Date: July 2016


Abstract


Clinical coding constitutes one of the fundamental functions in the field of health information management. Clinical classification systems and clinical terminologies represent two distinct sets of coding schemes that are used in healthcare. In this context, it is critica....

Semantic Content in EHR Systems

Author: Bhattacharyya, S. B; Warner, Diana

Source: Journal of AHIMA

Publication Date: June 2016



An electronic health record (EHR) can greatly help the timely delivery of efficient healthcare if the information it contains is adequate, accurate, and accessible in a timely manner. An EHR is a longitudinal record of an individual’s health journey made up of electronic documents from va....

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