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Learning More About Terminology Asset Management Trends, Principles, and Definitions

Author: Abrams, Kelly; Giannangelo, Kathy; Schneider, Sue; Scichilone, Rita A

Source: Journal of AHIMA | AHIMA web extra

Publication Date: February 2014



Terminology asset management (TAM) in healthcare and research settings is an emerging role for HIM professionals, but requires certain skills and knowledge to move into these new TAM positions. This appendix is linked to the article “New Name of the HIM Game” published in the F....

Appropriate Use of the Copy and Paste Functionality in EHRs

Author: AHIMA

Source: AHIMA position statement

Publication Date: March 2014

Use of the copy and paste functionality in EHRs can result in redundant, erroneous, and/or incomprehensible health record documentation. Misuse of this functionality has the potential to result in or contribute to several overarching challenges, with implications for the quality and safety of patient care, medico-legal integrity of the health record, and fraud and abuse allegations.

E- Discovery Litigation and Regulatory Investigation Response Planning: Crucial Components of Your Organization’s Information and Data Governance Processes

Author: AHIMA

Source: AHIMA practice brief

Publication Date: November 2013

I. What is E-Discovery?



E-discovery is defined as the pretrial legal process used to describe the method by which parties will obtain and review electronically stored information. The 2006 Federal Rules of Civil Procedure (FRCP) served to place electronically stored information (....

EHR Train Has Arrived at the Station -- All Aboard!

Author: AHIMA

Source: AHIMA Advantage

Publication Date: February 2004


Many veteran HIM professionals remember first hearing about the electronic health record (EHR) in the late 1970s. "They were saying it was just around the corner," remembers Linda Frank, MBA, RHIA, chief operating officer at Servnet, Inc., an Evansville, IN-based healthcare IT consulting compan....

When the Doctor Calls: Opportunities in Ambulatory Care

Author: AHIMA

Source: AHIMA Advantage

Publication Date: August 2005


It wasn't too long ago that physicians could hire a file clerk to handle simple filing tasks and doctors themselves decided how patients could view their records. But today doctors' information needs are much more complex.
Just look at how many credentialed HIM professionals are bringing....

Meaningful Use Vocabulary Toolkit

Author: AHIMA

Source: AHIMA toolkit

Publication Date: April 02, 2013

This toolkit provides guidance to health information management (HIM) professionals and the industry on vocabularies as defined by ARRA’s meaningful use criteria. It includes a table of standard vocabularies required for Meaningful Use, a case study that shares lessons learned from Stage 1, and sample job descriptions to address the need for mapping professionals in the workplace.

Retention and Destruction of Health Information

Author: AHIMA

Source: AHIMA practice brief

Publication Date: October 2013


Editor's note: This update supersedes the August 2011 practice brief "Retention and Destruction of Health Information."



Health information management professionals traditionally have performed retention and destruction functions using all media, including paper, images, optic....

Time to Raise Your Standards?

Author: AHIMA

Source: AHIMA Advantage

Publication Date: August 2006


Are you ready to take your knowledge of standards to the next level?


HIM professionals will soon be working with standards more than ever before. We will…

…actively contribute to EHR product development as purchasers and employers.

… create....

Health IT Standards Committee Takes On Patient-Generated Health Data

Author: AHIMA Advocacy and Policy Team

Source: Journal of AHIMA

Publication Date: March 2014

Efforts from the Office of the National Coordinator for Health IT (ONC) in the area of patient-generated health data began in 2011. With mobile health on the rise and the “meaningful use” EHR Incentive Program progressing throughout the US healthcare system, these efforts continue to grow in importance to the future of healthcare and health information.

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....

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....

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....

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....

Guiding the Development of Health Information Technology Standards for HIM Practices

Author: Bailey-Woods, Linda; Munns, Megan; Orlova, Anna; Rhodes, Harry B.; Warner, Diana

Source: Journal of AHIMA

Publication Date: August 2015



Interoperability of health information systems will enable clinicians to communicate with their patients and each other using information and communication technology to enable safer, effective, and efficient care, and improve population health. Health information technology (HIT) standard....

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