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Managing Audit Trails

Author: Nunn, Sandra L.

Source: Journal of AHIMA

Publication Date: September 2009


Audit trails are records with retention requirements, and HIM professionals should include them in their management of electronic health record content. Legal and compliance needs drive audit trail management, but it is complicated by the challenges that IT departments face in storing these la....

Channeling HIM Skills into a Passion

Author: Zender, Anne

Source: Journal of AHIMA

Publication Date: September 2009


As a member of AHIMA’s E-Health Task Force in 1999–2000 and an early facilitator of AHIMA’s e-Health Community of Practice, Lynda Mitchell, RHIA, CPHQ, could see that the Internet had great potential for healthcare and communication. A decade later, the potential has become r....

Help Wanted: Schools Struggle Placing Students in PPEs

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: September 2009




Well-trained students make well-trained new hires, which is why professional practice experiences are an important part of HIM education. However, PPE coordinators say it is getting harder to place students in today’s hectic workplace. Yet the benefits, they say, are there for e....

Quality Clinical Documentation—A Costly Challenge

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: September 2009


The debate continues over how to reform healthcare while controlling costs and spending. The options are complex and controversial, and after decades of failed cost and spending control efforts, it’s not surprising that there is skepticism.

Reforming one of the world’s mo....

Getting a Yes for PPE Placements

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: September 01, 2009





“No” is a common word heard by PPE coordinators.


Getting busy HIM professionals to host an HIM student for a professional practice experience can be a challenge. As important as the internships are in giving students real-world experience, PPE coordin....

Preparing for ICD-10-CM in Physician Practices

Author: Kuehn, Lynn

Source: Journal of AHIMA

Publication Date: August 2009




What will change under ICD-10-CM, and what must be done to prepare? This is the year for physician practices to get their ducks in a row: become informed, assess their IT and training needs, and make a plan that leads to the October 1, 2013, deadline.



On September....

Physician Practice EHR Resources

Author: Dinh, Angela K.

Source: Journal of AHIMA

Publication Date: August 2009



Editor's note: This article updates the February 2006 Journal of AHIMA column "Resources to Assist Physician Office EHR Selection and Implementation."


[Note: The links in this article were accurate at the time of publication.]




EHR Public and Priva....

Managing the Unintended Consequences of EHRs

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: August 2009


Broadly deployed health information and communication technology is crucial to every aspect of healthcare reform. Financial assistance through ARRA should speed EHR adoption via financial incentives and other forms of support. This, in turn, will cause unintended and unforeseen consequences. <....

HIM in Physician Practices
: Comparing Health Information Management in Physician Practices and Hospitals


Author: Warner, Diana; Washington, Lydia

Source: Journal of AHIMA

Publication Date: August 2009


The majority of HIM professionals still practice in hospital settings and are most familiar with the HIM functions performed there.1 However, HIM professionals in hospitals frequently work with doctors in private practice, and HIM career opportunities may well grow in physician practices due t....

Physician Practice Check-Up: Assessing a Practice’s Readiness for Electronic Health Records


Author: Crocker, Janice; Fahrenholz, Cheryl Gregg; Johnson, Wanda; Levinson, Stephen R; Washington, Lydia

Source: Journal of AHIMA

Publication Date: August 2009




Federal incentives will take some of the pain out of transitioning a practice to an electronic health record system, but the transformation will be monumental, nonetheless. For practices that take the leap, focusing initial efforts on a readiness assessment lays a solid foundation for....

Preparing for ICD-10-CM: A Clinician's Perspective

Author: Rose, Eric

Source: Journal of AHIMA

Publication Date: July 2009


America’s physician practices are facing the biggest change in healthcare coding in decades: the replacement of ICD-9-CM by ICD-10-CM. This article discusses ICD-10-CM from a clinical perspective and reviews how electronic health record (EHR) systems will need to adapt to the transition.....

Present on Admission: Where We Are Now

Author: Garrett, Gail S.

Source: Journal of AHIMA

Publication Date: July 2009


Hospitals have nearly two years of POA reporting under their belts. With time, effort, and updates, assigning POA indicators is becoming routine business for coding professionals.

For the past several years, HIM professionals have served as a conduit for a rapidly evolving pay-for-pe....

Mortality Coding Marks 10 Years of ICD-10

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: July 2009


Morbidity coders rarely see a mortality code. But for 10 years the National Center for Health Statistics has been busy compiling mortality data coded in ICD-10.


There are a thousand ways to die in this life, and the National Center for Health Statistics tracks every one of the....

New Guidance for Home Health Coding

Author: Blevins, Ida K.

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2009


Sweeping PPS changes for home health went into effect January 2008, making much of the prior coding guidance issued by the Centers for Medicare and Medicaid Services (CMS) incompatible with changes in the revised data collection set. Home health coding professionals anxiously awaited further i....

Wider World of Coding

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: July 2009


Coding reminds me of the parable of three blind men describing an elephant. Each one touches just one part of the elephant.

The blind man who examined the elephant’s tail likened it to a straw fan swinging back and forth; the man who explored the legs described the elephant as....

Gauging Coding’s Evolution

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: July 2009


The influx of information technology in the healthcare industry has led many to wonder what the future holds for coding and what coders must do to remain vibrant and knowledgeable.

Back in 2000, the coding futures task force asked the same questions. In the Journal article “A C....

Healthcare Disparities and the Role of Personal Health Records

Author: Garvin, Jennifer Hornung; Odom-Wesley, Barbara; Rudman, William J.; Stewart, Rachelle S.

Source: Journal of AHIMA

Publication Date: June 2009



The Institute of Medicine defines disparities in healthcare as racial or ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs preferences, and appropriateness of intervention.1 Geographic isolation, poverty, lack of trained healthcare....

HIPAA: 43,691 Privacy Complaints and Counting

Author: AHIMA

Source: Journal of AHIMA

Publication Date: June 2009


For those wondering what progress the Office for Civil Rights makes as it works through HIPAA privacy rule complaints, the numbers are easy to find. Each month OCR reports top-line results of the HIPAA cases it has received and resolved.

OCR has logged approximately 43,700 complaints....

Linking Medical Librarians and PHRs

Author: Sweet, David A.

Source: Journal of AHIMA

Publication Date: June 2009


Medical librarians are a key source of information on healthcare topics. Their role is expanding with the boom in personal health record (PHR) products. In May 2007 Jean Shipman, president of the Medical Library Association (MLA), and Donald Lindberg, MD, director of the National Library of Me....

Information Therapy: A New Interest for HIM

Author: Burrington-Brown, Jill

Source: Journal of AHIMA

Publication Date: June 2009



HIM professionals involved in patient advocacy and the personal health record will have an interest in information therapy: getting patients the information they need to better manage their health.

Information therapy (Ix) is of interest in health information management, particu....

Thinking Lean in Healthcare

Author: Campbell, Robert James

Source: Journal of AHIMA

Publication Date: June 2009


Lean thinking is the efficient use of staff, resources, and technology to provide the highest level of service possible to the ultimate healthcare customer: the patient.

In today’s volatile healthcare environment, health information managers are being asked to do more with less....

ICD-10-CM Official Coding Guidelines

Author: Barta, Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2009


One of the keys to a successful transition to ICD-10-CM/PCS is a thorough understanding of the ICD-10-CM Official Coding Guidelines, which were posted to the National Center for Health Statistics Web site in January 2009. Similar to the ICD-9-CM coding guidelines, the ICD-10-CM guidelines are....

Understanding National Coverage Policies: Navigating the Maze of HACs, Serious Reportable Events, and Wrong Surgical Sites

Author: Cook, Jane; D'Amato, Cheryl; Garrett, Gail S.; Ruhnau-Gee, Becky; Hyde, Linda A.; Novak, Natalie

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2009


Present on admission indicators, hospital-acquired conditions, serious reportable events, and “wrong” surgical events are each hot topics. However, they also can be a hot topic together, because a number of these reporting requirements are interrelated. HIM professionals must under....

Testing Health Record Banking

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: May 2009


Washington State’s experiment in consumer-controlled health records has moved into a pilot phase, transforming the health record banking model from theory to testing. In March the Washington State Health Care Authority (HCA) announced the launch of three pilot sites that will try out the....

Student Makes “Right Decision” with HIM

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: May 2009


With seven physicians in her family, Sarah Keppen felt destined to go into healthcare. However, working directly with patients, needles, and other messy details never appealed to the 25-year-old.

While talking with her pediatrician mother about other healthcare careers, she learned o....

Dealing with Paper Post–Document Imaging

Author: Dinh, Angela K.

Source: Journal of AHIMA

Publication Date: May 2009


The electronic health record (EHR) has been a work in progress for decades. According to a 2007 American Hospital Association information technology survey, 68 percent of hospitals have a partially or fully implemented EHR.1

Today’s health information environment is made up of....

Sequestering EHR Data in IT Systems

Author: Miaoulis, William M

Source: Journal of AHIMA

Publication Date: May 2009


There can be three situations under which healthcare organizations may need to sequester (or segregate) certain data within a medical record: placing a legal hold in connection with litigation, limiting disclosures of a record pursuant to a request by a patient, and restricting access to sensi....

Medical Identity Theft and the Red Flags Rule

Author: Apgar, Chris

Source: Journal of AHIMA - website

Publication Date: April 2009


Continuing our Health Information Privacy and Security Week series, today Chris Apgar, CISSP, president of Apgar & Associates LLC, takes a look at medical identity theft within the context of the Red Flags Rule.

Much is reported in the news about identity theft including new cat....

Taking a Stand on Sanctions

Author: Rulon, Vera

Source: Journal of AHIMA - website

Publication Date: April 2009


The Journal of AHIMA kicks off our Health Information Privacy and Security Week series with a post from AHIMA president Vera Rulon, MS, RHIT, CCS, FAHIMA. Rulon is director of strategy and communications in the chief medical office of Pfizer, Inc.

So I get this communication that my c....

ICD-10 Reimbursement Mappings: New Mappings from CMS Help Organizations in the Transition to ICD-10

Author: Butler, Rhonda R.; Mills, Ronald E

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2009


Starting October 1, 2013, healthcare claims will be submitted to payers using ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes. Some payers such as the Centers for Medicare and Medicaid Services (CMS) are converting their reimbursement systems to use ICD-10 codes directly. However, som....

HIM’s Role in Reducing Health Disparities

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: April 2009


Health disparities are a major concern in the healthcare industry. Many studies related to health disparities cite the need for accurate and accessible data to identify where the differences in health exist.

“The National Healthcare Disparities Report” from the Agency for....

Advancing Quality Measures Reporting in HIEs

Author: Barrows, Randolph C. Jr.

Source: Journal of AHIMA

Publication Date: April 2009


Members of the NHIN Cooperative demonstrated significant interoperability advances in support of healthcare quality measurement, feedback, and reporting at the 5th Nationwide Health Information Network (NHIN) Forum last December. The public forum included demonstrations of technology developed....

Using Document Imaging to Strengthen Revenue Cycle

Author: Clark, Jill S

Source: Journal of AHIMA

Publication Date: April 2009


For many organizations, document imaging is the first step toward implementing a fully electronic health record. Document imaging allows staff members across an organization to access electronic documents simultaneously. Three practitioners share their experiences on how this accessibility can....

First Health Record Bank Pilot Launches

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: March 30, 2009





Washington State’s experiment in consumer-controlled health records has moved into a pilot phase, transforming the health record banking model from theory to testing. Earlier this month the Washington State Health Care Authority (HCA) announced the launch of three....

Street Smart: Understanding the Context of Emergency Medical Services Communication and Documentation

Author: Teslow, Mary; Harris, Susie T.; Wilfong, Denise

Source: Journal of AHIMA

Publication Date: March 2009


HIM professionals can expand their understanding of the healthcare continuum by becoming more familiar with hospital emergency care and documentation.

Emergency medical services (EMS) has evolved into an integral part of the healthcare system. The field is working to integrate itself....

Streamlining the Revenue Cycle Management Process

Author: Zender, Anne

Source: Journal of AHIMA

Publication Date: March 2009


Keeping an organization’s revenue cycle running smoothly is no small feat. But Patsy Hathorn’s team at Mississippi Baptist Medical Center in Jackson, MS, volunteered to take it on. Now the team is seeing results.

Hathorn, RHIA, who is director of clinical resource managem....

HIM Breakup: Changing Times Pull HIM and Coding Apart

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: March 2009


Benefits can follow when coding packs its bags and moves to the revenue cycle. But all realignments have their opportunities and risks.

HIM and coding are breaking up.

Once a common couple, the two departments are beginning to split at some facilities, moving on to differen....

Communities of Practice—HIM’s Social Network

Author: Rulon, Vera

Source: Journal of AHIMA

Publication Date: March 2009


Social media has boomed with the advent of online networking sites such as Facebook, MySpace, and LinkedIn. Now healthcare is getting involved, too.

One can only imagine the impact the new ways of patient-doctor, consumer-consumer, and doctor-doctor communications will have on health....

Key Issues in the 2009 OPPS Final Rule

Author: Clark, Andrea

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2009


The final rule for the 2009 Outpatient Prospective Payment System (OPPS) includes multiple revisions that hospitals must address in their practices, policies, and operations. Hospitals should develop strategies for analyzing the financial impact and operational challenges by reviewing the foll....

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