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Key Points of the UB-04 (2010 update)

Author: AHIMA Clinical Terminology and Classification Practice Council; Garrett, Gail S.; Jorwic, Therese M; Novak, Natalie; Ruhnau-Gee, Becky; Safian, Shelly C; Zeisset, Ann M.

Source: AHIMA practice brief

Publication Date: April 2010


Editor’s note: This update replaces the October 2006 practice brief “Key Points of the UB-04.”

In 2005 the National Uniform Billing Committee (NUBC) approved the Uniform Bill (UB-04) paper claim and data set as the replacement to the UB-92 paper form.1 Currently, all paper claims must....

Electronic Signature, Attestation, and Authorship. Appendix A: HL7 EHR-System Records Management and Evidentiary Support (RM-ES) Functional Profile Standard Excerpt (2009 update)

Author: AHIMA e-HIM Work Group: Best Practices for Electronic Signature and Attestation

Source: AHIMA practice brief attachment

Publication Date: November 2009


The records management and evidentiary support functional profile standard is a subset of functions and conformance criteria from the HL7 EHR-S Functional Model standard. The standard was created specifically to address requirements and criteria for basic record management functionality in EHR....

Assessing and Improving EHR Data Quality: Model for Implementing an EHR Documentation Improvement Process

Author: AHIMA e-HIM Work Group on Assessing and Improving Healthcare Data Quality in the EHR

Source: Journal of AHIMA

Publication Date: March 2007


Improving data quality in an electronic healthcare environment requires a greater focus on standardized documentation procedures. With an EHR, the need to evaluate and improve healthcare data quality through concurrent assessment, data collection monitoring, and ongoing process improvement requ....

Journal Q&A (2/00)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: February 02, 2000

Q: What Internet security guidelines are available?
A: Initially, Medicare issued a statement that the Internet was not secure enough for transmission of sensitive data. However, the growing demand for transmittal of HCFA Privacy Act-protected data via the Internet resulted in HCFA's....

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 (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?
....

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 (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 (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 ....

Journal Q&A (2/01)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: February 02, 2001

Q: What are data sets?

A: Data sets support and encourage the uniform collection and reporting of data. They have been developed for different healthcare settings and are used to categorize patient data. Data sets are intended to describe significant minimal data about patients, residents....

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....

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 (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....

Journal Q&A (1/01)

Author: AHIMA Staff

Source: AHIMA Q and A

Publication Date: January 01, 2001

Q: Can a healthcare facility release health information for marketing purposes?

A: There is a growing demand for and supply of health information for uses that are far removed from patient care or the payment process. It is imperative for a facility to establish a system of controls for id....

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....

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....

Managing the Integrity of Patient Identity in Health Information Exchange (2014 update)

Author: AHIMA Work Group

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: May 2014

This Practice Brief explores the complexity of patient identification integrity, including how organizations can manage patient identification systems from front end data capture to back end quality control as an ongoing process and carry local quality operations into health information exchange efforts. It urges industry stakeholders to recognize that now is a critical time to address accuracy in patient identification systems.

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....

Utilizing Open-Source Government Data Sets in Health Information Management Teaching: An Application in Statistics and Data Analytics

Author: Alakrawi, Zahraa M; Watzlaf, Valerie J.M.; Aborde, Jon; Johnson, Carey; Johnson, Timothy

Source: Educational Perspectives in Health Informatics and Information Management

Publication Date: July 2016


Abstract


The American Health Information Management Association (AHIMA) Council for Excellence in Education acknowledges the importance of improving the data analytics skills of health information management (HIM) students at the baccalaureate level. This importance is especially....

Personal Genomic Information Management and Personalized Medicine: Challenges, Current Solutions, and Roles of HIM Professionals

Author: Alzu'bi, Amal; Zhou, Leming; Watzlaf, Valerie J.M.

Source: Perspectives in Health Information Management

Publication Date: April 2014


Abstract


In recent years, the term personalized medicine has received more and more attention in the field of healthcare. The increasing use of this term is closely related to the astonishing advancement in DNA sequencing technologies and other high-throughput biotechnologies. A l....

Primer on Encryption

Author: Amatayakul, Margret

Source: Journal of AHIMA

Publication Date: June 2004


Encryption is an addressable implementation specification under HIPAA’s access control and transmission security standards. Many providers are grappling with just how to address these specifications:
Is there a difference between the two specifications, and if so, what is the diff....

Managing HIPAA as Gatekeeper

Author: Amatayakul, Margret

Source: Journal of AHIMA

Publication Date: September 2004


An unfortunate result of the HIPAA privacy rule is the emerging use of HIPAA as a gatekeeper, restricting the appropriate fl ow of protected health information (PHI). HIPAA is being cited as a reason not to disclose information without patient permission when needed for treatment, payment, or....

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