Author: Clarke, Zada; Hill, Angela M.

Source: Journal of AHIMA

Publication Date: September 2006

Professional development plans help you chart your professional course, then help you steer there. Keep them simple and revisit them regularly.
We remember being told a long time ago that for a sailboat that has no port in mind, there is no such thing as a fair wind.

If you don....

Author: Clark, Holly

Source: Journal of AHIMA

Publication Date: October 1998

Is speech recognition a futuristic dream, an emerging technology, or a current reality? How vital is speech input to a computerized patient record strategy? How can you influence your organization to investigate speech recognition options that best meet its needs? There are no simple answers t....

Author: Clark, Jean S.

Source: Journal of AHIMA

Publication Date: October 1998

The Executive Board of the International Federation of Health Records Organizations (IFHRO) held a strategic planning and business meeting last spring to discuss the organization's direction. The meeting took place in conjunction with the European Health Records Congress ....

Author: Clark, Jean S.

Source: Journal of AHIMA

Publication Date: June 2004

For years health information managers have coordinated ongoing record reviews. From the early days of “clinical pertinence” review to the most recent “19 items” review, the jury is still out as to whether the process really improved documentation. With the Joint Commis....

Author: Clark, Jean S.

Source: Journal of AHIMA

Publication Date: January 2002

HIM professionals are well aware of the challenge of meeting Joint Commission standards. Now, however, a recently established review committee has the opportunity to recommend changes to the standards—and may even be able to reduce the burden of compliance.


That’s the....

Author: Clark, Jean S.

Source: Journal of AHIMA

Publication Date: October 2002

When the Joint Commission standards related to clinical pertinence review were revised, flexibility and an ongoing process for review of medical records at the point of care was the intent. This continues to be the goal of IM.7.1-IM7.10.1, though there are still directions in the requirement t....

Author: Clark, Jean S.

Source: Journal of AHIMA

Publication Date: February 2000

For HIM professionals working at organizations surveyed by the Joint Commission on Accreditation of Healthcare Organizations, the information management standards are critical. Here's an overview of the key points and top issues surveyors look for.
Whether you work in acute, long term, h....

Author: Clark, Jill S

Source: Journal of AHIMA

Publication Date: February 2011

Healthcare entities collect a vast amount of administrative, clinical, and financial data. Health data analysts play a critical role in helping translate these data into meaningful information that can be used to identify improvement opportunities, recognize trends, and assist in decision maki....

Author: Clark, Jill S

Source: Journal of AHIMA

Publication Date: June 2013

During her speech at the 2013 HIMSS Annual Conference, the Centers for Medicare and Medicaid Services’ Acting Administrator Marilyn Tavenner said the healthcare industry should proceed full steam ahead on preparing to implement ICD-10-CM/PCS. The message conveyed is that CMS is 100 p....

Author: Clark, Jill S

Source: Journal of AHIMA

Publication Date: March 2012

Transitioning out of a 30-year-old classification system has many in the healthcare industry asking why. The expense, the implementation timeline, and the intent of the transition have all been questioned.

The truth is the implementation of ICD-10 CM/PCS will have a tremendous impac....

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....

Author: Clark, Susan

Source: Journal of AHIMA

Publication Date: May 1998

The value of obtaining physician signatures on verbal orders after the patient's discharge from care is a concept that has been debated for several years. Typically, state regulations require that verbal orders be signed or authenticated. In some states a specific time frame—such....

Author: Clark, Susan; Leri, Patti

Source: Journal of AHIMA

Publication Date: February 1998

After healthcare organizations merge, how do employees of different work cultures integrate? A study of four Colorado facilities in one delivery system reveals where employees reported similarities, differences, and problems— and the author tells how these issues were add....

Author: Claybrook, Deresa

Source: Journal of AHIMA

Publication Date: April 2007

The story made national headlines: a VA employee who worked from home had his house broken into, and a burglar stole a laptop with valuable identifying information on it. The story got a lot of publicity because of the privacy and security concerns that we all have about our personal info....

Author: Coffey, Bonnie; Paulson, Justine

Source: Journal of AHIMA

Publication Date: October 2012

Release of Information (ROI) continues to be an integral component of the health information management (HIM) department. Before copiers and fax machines, medical record librarians would create a handwritten abstract of a patient’s medical history and then mail it to the requestor through the....

Author: Coffey, Patricia S; McKeeby, Jon W; Starr, Marisa RHIA; Lardner, Michelle DNP, RN-BC

Source: Journal of AHIMA

Publication Date: November 2018

By Patricia Coffey, RHIA, CPHIMS, CPHI; Marisa Starr, RHIA; Michelle Lardner, DNP, RN-BC; and Jon Walter McKeeby, D.Sc., MBA, CPHIMS, CPHI


A robust information governance program helped the National Institutes of Health Clinical Center (NIHC....

Author: Coffman-Kadish, Nancy; Hanchar, Ron

Source: Journal of AHIMA

Publication Date: June 2006

It’s a long journey from draft question to scored item. The Council on Certification takes its job of developing credentialing exams seriously.
The AHIMA Council on Certification (COC) provides oversight and administration for all AHIMA certification exams. The council, which consi....

Author: Cohn, Simon P.; Chute, Christopher G.

Source: Journal of AHIMA

Publication Date: February 1997

Introduction


Words, terms, and codes have had clearly understood functions within patient records for well over a century. Historically, caregivers would describe patient conditions and findings in prose transcriptions, using technical terms for precision and concise communic....

Author: Colburn, Charlotte

Source: Journal of AHIMA

Publication Date: February 1997

Background

Documentation of patient encounters through dictation and transcription processing has advanced dramatically over the past century, and current technology offers still greater opportunities for efficiency, timeliness, and completeness. Sixty years ago, the "transcriptionist" o....

Author: Coleman, Johnathan

Source: Journal of AHIMA

Publication Date: April 2014

Sensitive health information is not a rarity in the United States by any means, according to a recent Issue Brief published by the Office of the National Coordinator for Health IT (ONC).1 In the brief, ONC estimated 26 percent of Americans age 18 and older are living with a mental health d....

Author: Coleman, Johnathan

Source: Journal of AHIMA

Publication Date: February 2013

Not all protected health information (PHI) is created equally. Some health data requires special handling according to law, organizational policies, or patient preferences. For appropriate sharing of health information to occur, a patient must trust that a provider organization will proper....

Author: Collins, Christine M.

Source: Journal of AHIMA

Publication Date: June 1998

Education and training play a considerable part in efforts to enhance data quality in healthcare. How do other fields work toward data consistency? The author describes how professionals in the pharmaceutical industry manage their data.

Today healthcare data serve a variety of sign....

Author: Collins, Patricia

Source: Journal of AHIMA

Publication Date: October 1999

The decision to implement a computer-based patient record (CPR) system is a substantial commitment of time and resources. Making it a reality in your organization requires a number of steps, not the least of which is risk assessment. Assessing the risks associated with the CPR should ....

Author: Columbus, Suzanne

Source: Journal of AHIMA

Publication Date: May 2006

A thorough plan and a structured approach keep your criteria on target, your progress on track, and your vendor list manageable.
Purchasing an electronic health record (EHR) system is probably one of the most important decisions a small physician practice will make. The systems require m....

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: August 25, 2016

The Hospital Value-Based Purchasing (HVBP) Program has heightened hospital awareness of quality outcomes. Under this program, payments made under the Inpatient Prospective Payment System (IPPS) are based on the quality of care that was provided. Quality of care is recognized through the cl....

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: July 27, 2016

We talk a lot about the impact of clinical documentation improvement (CDI) on healthcare organizations and physicians. We look at ways to reflect appropriate reimbursement and accurate quality scores, both of which are very important. But do we take the time to look at the true extent of t....

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: September 28, 2016

Have you ever gone to a staff meeting only to hear the news that a process you’ve been following for years is about to change? How does that make you feel? Maybe you love change and welcome any opportunity to improve a process. But maybe you are a creature of habit and the thought of a cha....

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: October 27, 2016

Mastering physician engagement can be a challenging process, but it is within reach when you develop a plan of action and have a little patience. During AHIMA’s 2016 CDI Summit: Advancing the Documentation Journey, held August 1-2 in Washington, DC, Dr. John Showalter, MD, MSIS, University....

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: November 23, 2016

Have you ever spent hours working on a project, only to find out at a random meeting that another team has been working on the same project? This type of scenario can be frustrating to both teams and lead to distrust in the work process—not to mention wasted time that could have been spent....

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: June 23, 2016

Clinical documentation improvement (CDI) programs are quickly emerging in various areas of the healthcare arena. We now see these programs specializing both prior to and beyond the acute hospital admission. Just as healthcare doesn’t stop when a patient is discharged, health problems begin....

Author: Combs, Tammy

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2018

By Tammy Combs, RN, MSN, CDIP, CCS, CCDS


Have you ever wondered what it means to be an effective communicator? In his article “Why Communication Is Today’s Most Important Skill,” Greg Satell discusses Michael Faraday, who helped tr....

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: January 27, 2016

When an architect draws up plans for a building, they pay close attention to the details of the foundation. This provides the support to the building and prevents it from crashing down at any moment. If the building later has structural damage it is easy to fix when the foundation is not i....

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: April 27, 2016

If a couple were to decide they wanted to build a house, they would need to communicate regularly to complete the home and make sure it fit the needs of both of them. If one of them were to say, “We need three bedrooms,” and the other one instead said, “No, we must have four bedrooms,” the....

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: March 23, 2016

When calculating the productivity guidelines for a clinical documentation improvement (CDI) program it is important to remember both quantitative and qualitative perspectives. Sometimes it is very easy to focus solely on the quantity of reviews that are performed. If the quality of those r....

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: February 24, 2016

Understanding clinical documentation improvement (CDI) metrics can be confusing, especially when you first start reviewing them.


Let’s dive a little deeper into the topic and take a closer look at some frequently reported CDI metrics and evaluate how these measures can reflect the....

Author: Combs, Tammy

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

Publication Date: July 2016

Illness doesn’t care what country or region a person lives in, and it doesn’t care the race or origin of a person. Since illness is found everywhere around the globe it only stands to reason that providers should also look beyond the boundaries of one country or patient population when re....

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: May 27, 2016

Many hospitals that have implemented clinical documentation improvement (CDI) programs have seen a reduction of claim denials and an improvement in appropriate reimbursement payments and accurate quality scores. For these reasons, CDI programs have become very....

Author: Combs, Tammy

Source: Journal of AHIMA

Publication Date: April 2019

Analysis of AHIMA’s New Clinical Documentation Improvement Industry Survey


By Tammy Combs, RN, MSN, CCS, CDIP, CCDS


The AHIMA Clinical Documentation Improvement Practice Council (CDIPC) is a group of clinical documentation improvement (CDI) experts that meet once a....

Author: Combs, Tammy

Source: Journal of AHIMA

Publication Date: May 2016

When we take a bite of our favorite food we can easily determine the quality by relying on what our senses tell us. The look, smell, and taste are all clues to the quality that was put into preparing the meal. If it looks undercooked or has mold on it, smells foul or tastes bitter, we kno....

Author: Combs, Tammy; DeVault, Kathryn; Easterling, Sharon; Endicott, Melanie; Isom, Crystal; Lojewski, Tedi; Simmons, Cortnie R.; Wolf, Beth

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: June 2016

Editor’s Note. This Practice Brief has been updated. See the latest version at Guidelines for Achieving a Compliant ICD-10-PCS Query
. This version is made available for historical purposes only.




The complex and highly specific nature of ICD-10-PCS has changed....

Author: Combs, Tammy; Endicott, Melanie

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: July 2017

Physician engagement seems to be the buzzword in healthcare these days. Hospital administrators charged with various clinical improvement initiatives have come to realize that physician engagement is an essential element of success. While physician engagement in clinical documentation improveme....

Author: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2014

With only a few weeks left in 2013, the Hospital Outpatient Prospective Payment System (OPPS) final rule for calendar year (CY) 2014 was released on November 27, 2013 and went into effect on January 1, 2014. The final rule is normally provided to the public around the first week of Novemb....

Author: Comfort, Angie

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

Publication Date: February 2017

As last year drew to a close, facilities began the looming task of reviewing the Hospital Outpatient Prospective Payment System (OPPS) final rule to ensure their chargemaster and systems were up-to-date with the 2017 changes. The final rule for calendar year (CY) 2017 was released on Novem....

Author: Comfort, Angie

Source: Journal of AHIMA

Publication Date: February 2018

By Angie Comfort, RHIA, CDIP, CCS, CCS-P

The holidays have come and gone. Now, we must focus our professional attention on what did not “go” with the ringing in of the new year: those 2018 Current Procedural Terminology (CPT) code updates. As is customary for every January 1st,....

Author: Comfort, Angie

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

Publication Date: September 2017

The arrival of October 1, 2015 was met with anxiety, alarm, and even terror by many as the healthcare industry braced for what some called “another Y2K-like event”—the ICD-10-CM/PCS implementation. Fast-forward to September 2017, where we have been living in the post-ICD-....

Author: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2013

As 2012 drew to a close, US healthcare facilities began the daunting task of reviewing the Centers for Medicare and Medicaid Services’ (CMS) hospital outpatient prospective payment system (OPPS) update to ensure their chargemaster and systems were up-to-date with the 2013 changes. Th....

Author: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2012

More and more HIM department managers are turning to remote coding. However, before implementing this staffing model, managers must answer several questions regarding the privacy and security of patient information, including:
What are the compliance risks?
How will privacy and secu....

Author: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2013

Editor’s note: This article is the sixth in a series of 10 articles discussing the 31 root operations of ICD-10-PCS.


With the upcoming implementation of ICD-10-PCS, there are new definitions and descriptions used to describe the procedures performed. Coding professiona....

Author: Comfort, Angie

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2012

Fractures are a common medical malady, and coders encounter them often. But the differences between coding fractures in ICD-9-CM and ICD-10-CM are vast.

Upon implementation of ICD-10-CM the code system currently in place for fractures within ICD-9-CM will cease to exist, and a new,....

Author: Comfort, Angie; Maimone, Carol; Rugg, Donna

Source: Journal of AHIMA

Publication Date: February 2016

Starting with services provided on or after October 1, 2015, health systems across the country transitioned to coding with the International Classification of Diseases, 10th Revision (ICD-10). Implementation of ICD-10 is intended to deliver both immediate and long-term benefits including....

Author: Comfort, Angie; Rugg, Donna; Ward, Maria

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: June 2017

Editor’s Note: This update replaces the 2010 Practice Brief “The Evolution of DRGs.”


In the early 1970s Yale University developed diagnosis related groups (DRGs) to describe all types of patient care in an acute care hospital. The Yale system encompassed the Medi....

Author: Connor, Kathleen

Source: Journal of AHIMA

Publication Date: June 2007

As the US prepares to implement a nationwide health information network (NHIN), one issue that repeatedly surfaces is how to appropriately protect the privacy and security of electronic health information. Of particular concern is how such a system can accommodate the various legal restriction....

Author: Cook, Jane

Source: Journal of AHIMA

Publication Date: September 2012

As the healthcare community works to meet the requirements of the Centers for Medicare and Medicaid Services’ (CMS) “meaningful use” EHR incentive program and other initiatives, new opportunities are forming for the health information management (HIM) professional. Roles in both clinical data....

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....

Author: Cook, Jane; Foley, Margaret M.; Giannangelo, Kathy; Paterno, Marilyn D.; Scichilone, Rita A; Schwarz, Kathleen M.

Source: Journal of AHIMA

Publication Date: January 2009

Standardized clinical terminologies are critical connectors that allow systems to exchange health information.

In the winter of 1904 a major fire broke out in Baltimore, MD. The resulting damage—an entire swath of the downtown destroyed—was blamed largely on a lack of uni....

Author: Cooper, Mary; Ahern, Kitty; Dietz, Linda S.

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2000

This article has been abstracted from the AHIMA Nov. 4, 1999 audio seminar "National Correct Coding Initiative" conducted by the authors. For a copy of the complete 90-minute seminar tape, contact AHIMA at (312) 233-1100.
Since 1996, the Health Care Financing Administration (HCFA) has us....

Author: Cooper, Steve

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2004

Recent legislation included in both the Benefits Improvement and Protection Act (BIPA) and the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 has affected the content and implementation processes for Medicare coverage determinations. This column reviews differenc....

Author: Cooper, Ted

Source: Journal of AHIMA

Publication Date: July 2004

The first version of the Computer-based Patient Record Institute (CPRI) toolkit “Managing Information Security in Health Care” was published on the Web in May 1999 in response to the proposed HIPAA security and electronic signature standard of October 1998. The toolkit is intended....

Author: Coplan-Gould, Wendy; Carolan, Katie; Friedman, Beth

Source: Journal of AHIMA

Publication Date: July 2011

EHRs, CAC, ICD-10-coding is in the midst of profound change. Which makes this the best time to re-engineer coding workflow. Five steps help HIM professionals assess and evolve coding workflows with an eye toward tomorrow.

Synergism-where total outcome is greater than the s....

Author: Costa, Kerry F

Source: Journal of AHIMA

Publication Date: August 2010

This month providers will begin seeing the first EHR products approved for use in the "meaningful use" incentive program. Another piece of the ARRA puzzle is falling into place.

In March 2010 the Office of the National Coordinator (ONC) proposed two programs to test and approve EHR p....

Author: Cottington, Sarah

Source: Journal of AHIMA

Publication Date: September 2011

Reporting clinical quality measures from an electronic health record (EHR) system is new territory and can be challenging for providers. However, that is just what eligible professionals must do to participate in the meaningful use EHR incentive program.

Recognizing the challenge, t....

Author: Cottrell, Carlton

Source: Journal of AHIMA

Publication Date: September 2000

Coding quality for Medicare claims is an area of constant concern. Coding errors can have far-reaching effects in the healthcare universe, and coders are experiencing increased scrutiny from both regulators and hospitals looking to control costs. As a follow-up to results of a Medica....

Author: Cottrell, Carlton

Source: Journal of AHIMA

Publication Date: March 2007

By now, most people working in healthcare are familiar with the term electronic health record, or EHR, as well as the various forms that it might take. The legal EHR is not as well understood, particularly outside the HIM department, because many are unfamiliar with the term legal health....

Author: Cox, William G.

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2004

Effective January 1, 1988, a provision of the Balanced Budget Act of 1977 (Section 4511) removed restrictions on settings where nurse practitioners, physician assistants, and clinical nurse specialists provide services. The definition of a clinical nurse specialist was also modified to requir....

Author: Crabb, Stephanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: January 14, 2016

How are football and IG related? Anyone who knows me knows that I am a sports fanatic and football is my favorite professional team sport. So, as we stand on the precipice of the playoff season, I have football on my mind. With IG ALWAYS on my mind, I found myself thinking about how to ans....

Author: Crabb, Stephanie

Source: Journal of AHIMA

Publication Date: May 2019

By Stephanie Crabb, MA


The age of digital transformation across many industry sectors is in full swing. While healthcare often paces behind others when it comes to technology innovation and adoption, this is not the case with digital health—start-ups in this sector raised a record....

Author: Crabb, Stephanie; Fullem, Leah MHCDS

Source: Journal of AHIMA

Publication Date: February 2019

By Stephanie Crabb, MA, and Leah Fullem, MHCDS


Value-based healthcare IS changing how things work for everyone. The front end of this change—the way that clinicians, patients, and caregivers participate in healthcare—is anchored by the electronic health record (EHR) an....

Author: Crawford, Mark

Source: Journal of AHIMA - website

Publication Date: September 01, 2012

A new version of international EHR standards is paving the way for the development of more robust health IT and  health records.


Health Level Seven International (HL7), an organization accredited by the American National Standards Insti....

Author: Crawford, Mark

Source: Journal of AHIMA

Publication Date: February 2014

Health informatics is often considered to be an advanced level of health information management (HIM). It’s also in high demand—in addition to handling, storing, and retrieving health data more HIM professionals are getting involved in the decision-making process regarding what types of i....

Author: Crawford, Mark

Source: Journal of AHIMA

Publication Date: April 2011

Ethics can look easy on paper, but the working world offers some complex situations. Three scenarios illustrate how the AHIMA Code of Ethics provides a guide for examining ethical issues.

Anyone who is a member of AHIMA or holds its credentials agrees to abide by its code of ethics.....

Author: Crawford, Mark

Source: Journal of AHIMA

Publication Date: November 2010

Migrating their patient records to an EHR system is not the only challenge physician practices must manage when they are acquired by a larger organization. Good communication is the foundation of all success.

An increasing number of small physician practices are being acquired....

Author: Crawford, Mark

Source: Journal of AHIMA

Publication Date: May 2013

"Open Notes" Project Gives Patients Simple, Affordable, and Resoundingly Effective Access to Clinician Notes



Exactly who owns a patient's health record-answer, the patient-was once an unknown to many patients and non-HIM staff in healthcare. While HIM professionals have....

Author: Crawford, Mark

Source: Journal of AHIMA

Publication Date: September 2011

Healthcare needs more than EHRs, it needs people who can implement and maintain them. New federally sponsored health IT exams set workforce competencies, helping job seekers demonstrate knowledge and employers benchmark qualifications.

As the US moves toward industry-wide adoption of....

Author: Crawford, Mark

Source: Journal of AHIMA

Publication Date: February 2013

Patient portals are becoming commonplace in healthcare facilities, which have installed the technology to provide patients and physicians immediate online access to electronic medical records. Adoption of patient portals will continue to increase, driven in part by stage 2 “meaningfu....

Author: Crawford, Mark

Source: Journal of AHIMA

Publication Date: July 2013

HIM professionals have been looking for some truth and straight talk on computer-assisted coding (CAC). The technology has been billed as everything from the savior of coding-based bottom lines due to ICD-10-CM/PCS (ICD-10) to the automated destroyer of human coding jobs. As the technology....