Author: Crerand, William J.; Lamb, Jana; Rulon, Vera; Karal, Bilun; Mardekian, Jack

Source: Journal of AHIMA

Publication Date: November 2002

Data management's mission is to construct databases that are complete and high quality to meet a study's analytic objectives and comply with regulatory standards. In this article, we'll provide an overview of basic procedures and approaches used in the pharmaceutical industry to "build quality....

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....

Author: Crow, Lisa

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: March 08, 2017

Monthly bills. Monthly lunch meetings. Monthly delinquent medical record report. So many tasks occur once a month. But monthly external coding audits? Isn’t once a year enough? No, says healthcare provider organizations.


Butler Memorial Hospital in Butler, PA, and dozen....

Author: Crump, Dawn

Source: Journal of AHIMA

Publication Date: January 2014

Medicare's Recovery Audit Contractor (RAC) program began as a three-year, three-state pilot program in 2005 and went nationwide in 2009. The American Hospital Association (AHA) began tracking data collection in January 2010 and since then, according to AHA, the RAC program has recouped $2.....

Author: Crump, Dawn; Hennum, Jeannie

Source: Journal of AHIMA - website

Publication Date: March 2015

The Affordable Care Act (ACA) has a dramatic ripple effect on the healthcare industry—and will continue to create seismic shifts for many years to come. One important change for health information management (HIM) professionals to understand is the impact of ACA on health plan audits. Alre....

Author: Crump, Dawn; Tice, Carolyn

Source: Journal of AHIMA

Publication Date: October 2015

The mere mention of the words “payer audits” can send even the most confident and capable health information management (HIM) directors into downward spirals of frustration and overload. These feelings are well known to providers who have found themselves forced to tread the mu....

Author: Cuellar, Ed

Source: Journal of AHIMA

Publication Date: September 2004

As the healthcare industry continues its steady move toward comprehensive electronic medical record-keeping, there is one solution that could easily be implemented now using current technologies, that offers several baseline benefits to patients, providers, and payers. That solution is a phys....

Author: Cummins, Ruth; Waddell, Julie

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2005

Recently, there has been a significant amount of talk in the healthcare industry about revenue cycle improvement. So what is all of the excitement about? It is about the bottom line. Specifically, how we can improve our bottom line through more effective and efficient revenue cycle management.....

Author: Curry, Mary Pat; Trask, Lisa; Liederman, Eric; Hutchinson, David; Zeboski, Alice

Source: Journal of AHIMA

Publication Date: July 2004

Thoughtful software design and good communication are fundamental ingetting physicians to sign verbal orders within the 48-hour mandate. Fines help a lot, too.
What hospital in the United States hasn’t struggled to comply with mandates from their state and the Joint Commission on....

Author: Curtis, Clayton; Fenton, Susan H.

Source: Journal of AHIMA

Publication Date: April 1996

Introduction

Clinical data repositories (CDRs) are becoming the patient records of today and the foreseeable future. It is already clear that all clinical information, regardless of its origin (provider, patient, or even the computer itself), will someday be stored in a data repository (....

Author: Curtis, Elizabeth

Source: Journal of AHIMA

Publication Date: October 2005

As CPOE turns from vision to reality, what impact is it having on HIM? And what impact is HIM having on it?
Installing an order entry system in a busy hospital environment can be a huge undertaking for administration, information systems, nursing, ancillary departments, and the medical s....

Author: Czahor, Amy

Source: Journal of AHIMA

Publication Date: September 2017

The ability to analyze and report meaningful clinical data is fast becoming a core career objective and job requirement for clinical documentation improvement (CDI) professionals. Today’s CDI leaders are under increased pressure to promptly provide root cause analysis of CDI program....

Author: Czahor, Amy; Evans, Ginna; Friedman, Beth; Head, Erin

Source: Journal of AHIMA - website

Publication Date: August 01, 2016

The healthcare industry’s move from paper to electronic health records (EHRs) has spanned two decades. The implementation of ICD-10 took four years. Now the shift from fee-for-service to value-based reimbursement is upon us. Like most large healthcare initiatives, full realization of....

Author: Czarkowski, Lynette; Clark, Jill S

Source: Journal of AHIMA

Publication Date: November 2015

Information governance (IG) is evolving as a necessity in healthcare as institutions expand their footprint and partnerships to meet “meaningful use” and earn EHR Incentive Program payments, participate in accountable care organizations, and tackle other industry challenges suc....

Author: Czirr, Karen

Source: Journal of AHIMA

Publication Date: July 2000

Driven by current and potential privacy regulations and legislation, the Children's Hospital of Philadelphia (CHOP) decided to address employee understanding of information security. In 1999, CHOP, comprised of a hospital, rehabilitation facility, physician offices, satellites, and ambulatory....

Author: Czirr, Karen

Source: Journal of AHIMA

Publication Date: October 2001

HIM professionals make significant contributions to patient care, public health, and a healthcare facility's bottom line. Although the HIM professionals at The Children's Hospital of Philadelphia were busy implementing HIPAA and computer-based patient records, directing data qual....

Author: Dahlstrand, Harold

Source: Journal of AHIMA

Publication Date: May 2003

When bad days start to add up, you may be suffering from burnout. How can you diagnose and treat burnout in yourself and your employees? A career counselor offers answers.
No matter how much HIM professionals love their work, it’s not uncommon for them to experience burnout. One of....

Author: Dahlstrand, Harold

Source: Journal of AHIMA

Publication Date: July 2002

Why do some organizations consistently thrive in an era of ever-changing politics, regulations, and increasingly scarce resources? The answer is leadership. Winning organizations have excellent leaders who know how to make smart decisions and implement them quickly and effectively. Those who a....

Author: Dahlstrand, Harold; Hjort, Beth M.

Source: Journal of AHIMA

Publication Date: November 2002

Do you know where your HIM department is headed? HIM departments are affected by many external forces, yet a considered vision and anticipation of the unexpected can help to make the uncontrollable more manageable.


If you're an HIM leader, ask yourself these questions: What is....

Author: Dalander, Geoffrey; Willner, Sue; Brasch, Sam

Source: Journal of AHIMA

Publication Date: October 1997

Imagine: It has been a productive day. Although it is only Wednesday, you have accomplished all the items on your weekly to-do list. All the hospital and SNF records are coded and analyzed. The discharges from this past Monday have been billed. Ongoing audits of the medical records are now com....

Author: D'Amato, Cheryl; Garrett, Gail S.; Johnson, Laurie M.

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: November 2007

The final rule for the fiscal year 2008 inpatient prospective payment system (IPPS) went into effect October 1, 2007. The rule includes ICD-9-CM code changes, implementation of the new Medicare severity-adjusted (MS) DRG system, and a number of quality-related changes that affect how Medic....

Author: D'Amato, Cheryl; Hoag, Patience J.; Crocker, Elsa; Neville, Deborah; Carpenter-Barbee, Cheryl; Bartell, Laurie

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2002

Remember the glorious Knights of the Round Table who made Camelot famous? King Arthur created a meeting place with special significance, a roundtable at which every seat had equal worth. AHIMA has embraced the spirit of this concept in a program known as coding roundtables, which are designed....

Author: Dasher, John

Source: Journal of AHIMA

Publication Date: January 2007

DeKalb Medical Center, a not-for-profit hospital system in Decatur, GA, that serves approximately 500,000 patients annually, was looking for a way to secure HIPAA-covered personal health records. “We wanted to eliminate any potential risk of confidential information leaving the facility electro....

Author: Datskovsky, Galina; Hedges, Ron; Empel, Sofia

Source: Journal of AHIMA

Publication Date: February 2015

Editor’s note: This is the first in a series of four articles that will discuss the eight Information Governance Principles for Healthcare.


AHIMA’s newly introduced Information Governance Principles for Healthcare (IGPHC) provides a framework for healthcare organizations to....

Author: Datskovsky, Galina; Hedges, Ron; Empel, Sofia; Washington, Lydia

Source: Journal of AHIMA

Publication Date: June 2015

Editor’s Note: This is the third in a series of four articles that discuss the eight Information Governance Principles for Healthcare.


AHIMA’s new Information Governance Principles for Healthcare (IGPHC) provide a framework for healthcare organizations to leverage informati....

Author: Datskovsky, Galina; Hedges, Ron; Empel, Sofia; Washington, Lydia

Source: Journal of AHIMA

Publication Date: September 2015

Editor’s Note: This is the final installment in a series of four articles that discuss the eight Information Governance Principles for Healthcare™.


AHIMA’s Information Governance Principles for Healthcare™ (IGPHC) provide a framework for healthcare organizations to enhance....

Author: Datskovsky, Galina; Hedges, Ron; Empel, Sofia; Washington, Lydia

Source: Journal of AHIMA

Publication Date: April 2015

Editor’s note: This is the second in a series of four articles that discuss the eight Information Governance Principles for Healthcare.


AHIMA’s new Information Governance Principles for Healthcare (IGPHC) provides a framework for healthcare organizations to enhance their ab....

Author: David, Gary; Vinkhuyzen, Erik

Source: Journal of AHIMA

Publication Date: November 2013

Documents are a fundamental component of any organization. In fact, no organization can exist without filing the proper paperwork. Documents are such a pervasive part of our everyday life that almost every parody of office work involves the specter of a burdensome documentation requirement....

Author: Davies, Sharon

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: September 2016

Place an order at almost any fast food chain and you can expect to hear the cashier ask, “Do you want fries with that?” From fries to soft drinks to apple pie desserts, extras abound at any given restaurant. When working on the coding for physician visits, it’s important to keep all the p....

Author: Davies, Sharon

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: October 2017

One thing is for certain, everyone’s life will end someday. But who wants to broach this uncomfortable subject in a healthcare setting? The patient? The patient’s family? The primary care provider? The hospitalists?


Medicare has recognized the value of this servi....

Author: Davino, Margaret

Source: Journal of AHIMA

Publication Date: March 2004

Healthcare providers can outsource transcription, but they can’t outsource their obligation to safeguard privacy. Here’s how to minimize risk.
Healthcare providers are faced with multiple pressures, many of them financial. The need for management to meet financial constraints....

Author: Davis, Adrian

Source: Journal of AHIMA - website

Publication Date: September 2015

This year the American Telemedicine Association estimates more than 450,000 patients will see a doctor in the form of a virtual visit over a secure Internet connection. As new models for service delivery and population health emerge, virtual physician visits are fast becoming an important....

Author: Davis, Nadinia A.

Source: Journal of AHIMA

Publication Date: June 2003

Time not only flies when we’re having fun, but also when we’re filing paperwork, checking e-mail, and looking for our car keys. But you can add hours to your day by managing yourself rather than time. Here’s how.

As a nonrenewable resource, time is precious. There neve....

Author: Davis, Nadinia A.; Gentul, Marion K.

Source: Journal of AHIMA

Publication Date: March 2002

Are you hiring? This excerpt from AHIMA’s new publication, Effective Management of Coding Services, offers basic guidelines that coding managers can use to assess their facilities’ needs when recruiting applicants to fill a vacancy in the HIM department.
Step One: Perform a Ne....

Author: Davis, Nancy

Source: Journal of AHIMA

Publication Date: February 2009

Like many other privacy and security officers, I was vaguely aware of the Fair and Accurate Credit Transactions Act. I knew that the act, passed by Congress in 2003, was intended to provide consumers with protection from identity theft. I knew the Federal Trade Commission (FTC) was in charge o....

Author: Davis, Nancy

Source: Journal of AHIMA

Publication Date: June 2019

By Nancy Davis, MS, RHIA, CHPS


While serving as a system privacy officer for a Wisconsin-based healthcare system, the author of this article met regularly with the organization’s president to review privacy and security compliance. This time was spent reviewing breaches that membe....

Author: Davis, Nancy; Glondys, Barbara

Source: Journal of AHIMA

Publication Date: May 2016

Federal law prohibits the sale of firearms to certain individuals with a history of mental illness. Recent mass shootings have focused attention on the fact that the individuals perpetrating these crimes often had a documented history of mental illness which went undetected despite state a....

Author: Davis, Nancy; Lemery, Chrisann; Roberts, Kim

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: April 2005

This practice brief has been retired. It is made available for historical purposes only.

Author: Davoudi, Sion; Dooling, Julie A; Glondys, Barbara; Jones, Theresa D.; Kadlec, Lesley; Overgaard, Shauna M; Ruben, Kerry; Wendicke, Annemarie

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: October 2015

Editor’s Note: This Practice Brief supersedes the July 2012 “Data Quality Management Model (Updated),” the March 1998 “Checklist to Assess Data Quality Management Efforts,” and the June 1998 “Data Quality Management Model” Practice Briefs.

Author: Deakle, Mary S; DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2013

Several changes to the prospective payment system went into effect at the start of 2013, including coding changes affecting the M1024 Rule.


Reimbursement for home healthcare agencies (HHA) was converted to a prospective payment system by the Centers for Medicare and Medicaid....

Author: Dean, A. Andrews

Source: Journal of AHIMA

Publication Date: July 2019

By A. Andrews Dean, CPHIMS, CHDA, CPHI, CPPM, CPC


The Centers for Medicare and Medicaid Services (CMS) turned many healthcare information technology consultants’ heads in March 2018 when they announced the new MyHealthEData initiative—intended to continue CMS’s goal of digitizing....

Author: Delahoussaye, Elizabeth A

Source: Journal of AHIMA

Publication Date: February 2016

The primary objective of the House of Delegates (House), made up of delegates from AHIMA’s Component State Associations, is to look at professional issues affecting the health information management (HIM) profession both today and in the future. Essentially, this is a venue in which AHIMA....

Author: Delahoussaye, Elizabeth A

Source: Journal of AHIMA

Publication Date: October 2016

Health information management (HIM) professionals can pull meaningful information from privacy and security breach data to evaluate release of information (ROI) processes, uncover workflow risks, and implement corrective measures. While large scale breaches impacting millions of patients m....

Author: Delahoussaye, Elizabeth A

Source: Journal of AHIMA

Publication Date: October 2016

This has been a busy and engaging year for the members of the House of Delegates (HoD) as we build on the present and prepare for the future.


For those who may not be familiar with the HoD, it is a grassroots AHIMA member forum that governs the health information managemen....

Author: DeLoss, Gerald E.

Source: Journal of AHIMA

Publication Date: July 2010

In a typical legal action, judges have a different perspective on the production of electronically stored information (ESI) than do HIM professionals. The Federal Rules of Civil Procedure, case law, and past experiences with discovery disputes play an important role in how judges view e-discov....

Author: DeMasters, Dana

Source: Journal of AHIMA

Publication Date: May 2015

A police officer arrives in the emergency department of a hospital at 2 a.m. seeking information about a patient who was recently admitted following a motor vehicle accident. The officer suspects the patient was intoxicated while driving and assertively asks the nurse to tell him the resul....

Author: DeMasters, Dana

Source: Journal of AHIMA

Publication Date: May 2019

By Dana DeMasters, MN, RN, CHPS


Covered entities are sharing vast amounts of electronic protected health information (ePHI) with business associates (BAs)—from outsourcing entire information technology and patient billing departments to participating in health information ex....

Author: DeMasters, Dana; Deanna, Peterson

Source: Journal of AHIMA

Publication Date: February 2016

A police officer with a body-worn camera records video of an altercation in an emergency department involving a patient who has become violent. During the recording another patient not involved in the altercation has their image captured. The officer leaves the facility wit....

Author: Deming, Sally; Dooling, Julie A; Kadlec, Lesley; Kirby, Annessa; Munns, Megan

Source: Journal of AHIMA

Publication Date: April 2016

The 2015 Supreme Court decision requiring states to license a marriage between two people of the same sex and to recognize same sex marriage across state lines has widespread implications for health records management.1


This article will describe these implications and issu....

Author: Demster, Barbara

Source: Journal of AHIMA

Publication Date: July 2006

The breadth of available privacy and security literature can be daunting to even the most dedicated HIM professional. With the explosion of information on the Internet, access to authoritative-as well as questionable-resources is easy and instantaneous. The problem of access has morphed into o....

Author: Demster, Barbara

Source: Journal of AHIMA

Publication Date: January 2007

Every healthcare provider must customize its privacy and security program to fit its unique setting and needs. How an organization maintains its records (analog, paper, electronic, or mixed modes) drives its privacy and security procedures. While regulations provide the basic requirem....

Author: Demster, Barbara

Source: Journal of AHIMA

Publication Date: November 2006

On the surface, the HIPAA privacy rule's requirements dealing with disclosures to clergy appear straightforward. Three years after implementation, however, major hurdles still exist and processes need further clarification. Key issues center around how healthcare institutions assess and defi....

Author: Demster, Barbara

Source: Journal of AHIMA

Publication Date: September 2012

Technology has transformed the world of health information management (HIM), bringing about change for many of the field’s longstanding professional concepts and work methods. The classic rule of ownership in the words-on-paper era of health records was that “the paper (physical medium) belong....

Author: Dennis, Jill Callahan

Source: Journal of AHIMA

Publication Date: April 2008

The privacy rule is just six, but gaps in its coverage have already widened. Now some organizations are recommending that the rule—or something like it—expand to cover any organization that handles personal health information in any form.



Six years ago....

Author: Dennis, Jill Callahan

Source: Journal of AHIMA

Publication Date: September 2006

In October the House of Delegates will vote on a proposed change to AHIMA’s bylaws that would establish a more inclusive membership policy. The change would welcome new types of professionals interested in HIM into our active membership category. Right now, active membership is limited to thos....

Author: Dennis, Jill Callahan

Source: Journal of AHIMA

Publication Date: November 2006

Do you set goals for yourself? I do, though some of my personal resolutions never seem to survive the first half of the year. One of my personal goals for 2006 was to have a spotlessly clean desk at the end of every work day. If you could see me right now, you'd see just how unsuccessful tha....

Author: Dennis, Jill Callahan

Source: Journal of AHIMA

Publication Date: July 2006

How involved are you in setting the future direction of AHIMA? There are many ways for members to get involved, but one of the most potent and direct ways is in your choice of leaders.

AHIMA Elections


Each year members have an opportunity to vote for the association’....

Author: Dennis, Jill Callahan

Source: Journal of AHIMA

Publication Date: June 2006

It’s hard to believe that we’re midway through the calendar year. This is a good time to reflect on AHIMA’s year-to-date progress. Here are just a few of our key accomplishments so far. (To make it interesting, give yourself one point for each item you have already heard about....

Author: Dennis, Jill Callahan

Source: Journal of AHIMA

Publication Date: February 2001

The HIPAA-mandated privacy officer role offers a new opportunity for HIM professionals. What skills are required, and what needs to be done first? This article answers these questions.
As healthcare organizations roll out their plans for HIPAA implementation, many HIM profession....

Author: Dennis, Jill Callahan

Source: Journal of AHIMA

Publication Date: January 2006

I think there is something special about people who go into our profession and all healthcare professions. It revolves around that patient in the hospital, that resident in the nursing facility, that client in the mental health center, and that consumer maintaining a personal health record. <....

Author: Dennis, Jill Callahan

Source: Journal of AHIMA

Publication Date: March 2006

We're almost a quarter of the way through 2006, so it's a good time to measure our progress on our 2006 goals.

This year, one goal of AHIMA's board of directors is to develop a process to more deeply embed our association's strategy into our operations through the use of a balanced....

Author: Dennis, Jill Callahan

Source: Journal of AHIMA

Publication Date: May 2006

Imagine you’re the director of HIM at a large healthcare organization. Your organization is undertaking a large, high-stakes project: converting to an electronic health record (EHR). Now imagine a coworker--it could be an IT professional, a nurse informaticist, or a physician--tells you h....

Author: Dennis, Jill Callahan

Source: Journal of AHIMA

Publication Date: October 2006

AHIMA’s Convention Offers Great Networking, Educational Opportunities, But There Are Many More Ways to Stay Connected
This month thousands of members will gather in Denver, CO, for AHIMA’s 78th Convention and Exhibit. Attending the annual conference is a great way for members....

Author: Dennis, Jill Callahan

Source: Journal of AHIMA

Publication Date: April 2006

What's your organization's health information strategy? Having spent the last few months experiencing the healthcare system from the standpoint of a patient's spouse, I would suggest the following patient-centered actions.

Create patient-friendly processes to authorize the release o....

Author: Dennis, Jill Callahan

Source: Journal of AHIMA

Publication Date: February 2006

No one relishes the experience of being a patient or of having a family member be a patient. But being put in that position reminds us of the importance of accurate and complete health information, both for the healthcare system and for the individual patient.
The Power of PHRs

....

Author: Dennis, Jill Callahan

Source: Journal of AHIMA

Publication Date: November 2000

There’s more to ensuring the validity of a patient’s consent than getting a signature. Is your organization making sure that patients are successfully informed about treatments and procedures? Here’s what HIM professionals need to know about this communication process.
Getting a patient....

Author: Denny, Susan

Source: Journal of AHIMA

Publication Date: January 2008

Electronic work queues capture incomplete records, enabling quality improvement initiatives to do more, more easily.



More than two years ago Jupiter Medical Center went live with an electronic record and retrieval system. The system allows users to scan and v....

Author: Denton, Debra Beisel; Endicott, Melanie; Ericson, Cheryl E; Love, Tammy R.; McDonald, Lori; Willis, Daphne

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: July 2016

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Author: Derlink, Amy L; Schembari, Elaine

Source: Journal of AHIMA

Publication Date: March 2012

Responding to an audit can be hectic and stressful, but HIM professionals must remember to hold external record reviewers accountable to good privacy and security practices.

When you visit the hair salon, take an exercise class, or sit across from a financial planner, you expect them....

Author: Derr, John F.; O’Malley, Terrence A

Source: Journal of AHIMA

Publication Date: February 2013

Editor’s note: This is the third and final installment of a series reviewing the current and desired state of longitudinal care, as well as the steps healthcare stakeholders need to take to embrace this emerging quality measurement process.



E-quality measures....

Author: Desai, Anna

Source: Journal of AHIMA

Publication Date: May 2015

Today’s healthcare environment is driven by various economic and regulatory forces and technological advancements that bring both opportunities and challenges. Healthcare organizations need the right information at the right time to make accurate decisions regarding patient care and....

Author: Desai, Anna

Source: Journal of AHIMA

Publication Date: August 2013

Whether planning a summer vacation or the direction of a new business, one must consider the larger external environment. Consider a trip to the grocery store. You’d like to get this done as quickly as possible. You run into some traffic. There’s been an accident on the road you usually take t....

Author: De, Suman

Source: Journal of AHIMA

Publication Date: June 2012

Just as drivers must select the proper road map for planning a trip, healthcare organizations must also manage their code translation process through a defined road map.


This article provides essential guidance to healthcare organizations on adopting best practices that will....

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2011

The final rule for the FY 2012 Hospital Inpatient Prospective Payment System was released August 1, 2011. Changes in the rule went into effect with October 1, 2011, inpatient discharges.
MS-DRG Documentation and Coding Adjustment

The Centers for Medicare and Medicaid Services....

Author: DeVault, Kathryn

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2010

Root Operations That Alter the Diameter/Route of a Tubular Body Part and That Define Other Repairs


The medical and surgical procedure section of ICD-10-PCS contains most, but not all, procedures typically coded and reported in the hospital inpatient setting. This article is the th....