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Putting the EHR to the Test

Author: Hawkins, Fanny

Source: Journal of AHIMA

Publication Date: September 2002


Is clinical documentation significantly different before and after implementing the electronic health record (EHR)?
Believing that the development and implementation of an EHR strategy is required for success, Baylor College of Medicine sought to answer this question. This article present....

Owning the EHR and Information Governance at Your Facility

Author: Head, Erin

Source: Journal of AHIMA

Publication Date: August 2015



For many decades, health information management (HIM) departments have been the hub for information collected within healthcare organizations. HIM has frequently been referred to as the “medical records department” due to the perceived idea that the department’s main tasks are receiving a....

How to Respond to Subpoena and Discovery Requests

Author: Hedges, Ron

Source: Journal of AHIMA

Publication Date: November 2014



Health information management (HIM) professionals are frequently pulled into litigation due to their role as custodians of health records and protected health information. This role also can categorize them as parties to civil litigation, which obligates them to produce any relevant infor....

What It Means to Be Deposed

Author: Hedges, Ron

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: July 22, 2016




In this blog I talk about legal consequences. I usually provide current examples of what those consequences might be under a specific set of facts. Here, instead, I want to highlight a litigation-related event that readers might experience in the future—or perhaps already have: a depo....

ESI Meets Court Order

Author: Hedges, Ron

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: June 11, 2015



I’ve written for AHIMA on various subjects, including preservation and spoliation of electronically stored information (ESI). This month, I want to ask you to think about both.


To start, consider this premise: The parties to a civil action agreed to an order “on D....

Lost Data and Its Implications for Litigation

Author: Hedges, Ron

Source: Journal of AHIMA

Publication Date: August 2019


By Ron Hedges, JD


Healthcare providers deal with electronic information on a daily basis. Providers must expect that volumes and varieties of electronic information will increase exponentially with, for example, the rise of artificial intelligence in the diagnosis and treatment of....

Privacy and Security Risks with Biometrics

Author: Hedges, Ron

Source: Journal of AHIMA

Publication Date: September 2018









By Ron Hedges, JD


Collection and use of biometric information may be useful to healthcare providers looking for new and better ways to positively identify patients as well as fight fraud. Biometric technologies include facial recognition, retinal....

What Lies Ahead in 2016?

Author: Hedges, Ron

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: December 18, 2015





This is the last Legal e-Speaking post of 2015. I thought I would use it to predict what 2016 might bring in litigation and beyond. When looking ahead to the next year, there are many possible things that HIM professionals should keep an eye out for, but five stand out to m....

How and Why to Preserve Health Records During Litigation

Author: Hedges, Ron

Source: Journal of AHIMA

Publication Date: September 2014



The term preservation, when used in a legal context, refers to placing information identified as relevant to a civil or criminal US court case in a legal hold to ensure the data is not destroyed or tampered with.


Health information managers, or anyone who works with records....

Risks and Results of Data Spoliation

Author: Hedges, Ron

Source: Journal of AHIMA

Publication Date: October 2014



The September e-HIM Best Practices article answered some basic questions about preservation of records in the context of civil litigation. This article will consider the question, “What if something goes wrong?”

Spoliation Defined


Health information management (H....

Communicating Change with Style

Author: Helbig, Susan

Source: Journal of AHIMA

Publication Date: May 2003


With so many different types of changes occurring at so many different times in the work place, how does an HIM professional prepare the context for change? Context refers to both the circumstances in which change will occur and to those the change will affect, such as the HIM staff, administr....

Change and Transformation

Author: Helbig, Susan

Source: Journal of AHIMA

Publication Date: November 2006


The HIM profession has evolved over the last several decades, and AHIMA's surveys of focus groups on the HIM profession's image reflects that evolution. February 2000 and 2002 results showed that respondents saw HIM professionals as clerical (44 percent). In 2003, however, nearly half (48 pe....

Transition Management: Striking a Balance

Author: Helbig, Susan

Source: Journal of AHIMA

Publication Date: April 2003


Life in today’s healthcare organizations is challenging for everyone involved—patients, providers, third-party payers, vendors, and HIM professionals. As HIM professionals, we are constantly in a state of transition in some area of our practice, which can be both challenging and rewa....

Nursing Data, Classification Systems, and Quality Indicators: What Every HIM Professional Needs to Know

Author: Henry, Suzanne Bakken; Warren, Judith J.; Zielstorff, Rita D.

Source: Journal of AHIMA

Publication Date: May 1998

by Suzanne Bakken Henry, RN, DNSc, FAAN, Judith J. Warren, RN, PhD, FAAN, and Rita D. Zielstorff, RN, MS, FAAN

The nursing profession has developed a number of classification systems. What can HIM professionals learn from the processes and results? This article presents an overview of the....

Another Look at LOINC

Author: Herbst, Maida Reavis

Source: Journal of AHIMA

Publication Date: January 2002


We have all heard Logical Observation and Identifier Codes (LOINC) mentioned in the same breath with standards or medical vocabularies, but what are they exactly?

What Is LOINC?


LOINC is a niche vocabulary useful in reporting laboratory and clinical observations. The....

ABCs of Medicare Advantage

Author: Hernandez, Jeannette

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2008


Although most Medicare beneficiaries receive their health coverage through the traditional Medicare Part A and B fee-for-service programs, more and more beneficiaries are enrolling in Medicare Part C, referred to as Medicare Advantage (MA), to manage their healthcare costs.

By June 2....

Releasing Records from Other Providers

Author: Herrin, Barry S.

Source: Journal of AHIMA

Publication Date: November 2008


Question: Should organizations include records of other providers when responding to a release of information?

Answer: Yes. There are three reasons this is so.

First, there is no law or regulation that generally prohibits the redisclosure of information received from anot....

Releasing Information of Deceased Patients

Author: Herrin, Barry S.

Source: Journal of AHIMA

Publication Date: January 2009


Developed when modern law concepts were first formed, the mortmain, or “dead hand,” rule prevented the church from exercising undue influence over a soon-to-be-dead penitent to obtain a gift of an individual’s lands in remission of his or her sins. These statutes evolved over....

Identity Proofing: Just a Fancy Name for Verification?

Author: Herrin, Barry S.

Source: Journal of AHIMA

Publication Date: May 2007


Among the issues being brought to the fore in the movement to electronic health records (EHRs) is identity proofing. However, this is the same issue healthcare providers have faced for as long as patients have been contacting providers in ways other than face-to-face communications. This artic....

In New Role, Years of Experience

Author: Heubusch, Kevin

Source: Journal of AHIMA

Publication Date: May 2005


Scan Michelle Wieczorek’s credentials—RN, RHIT, CPHQ, CPUR—and consider how she came to work at the center of the external and internal Web sites of a major health system.

The biggest reason doesn’t have to do with knowing how information becomes pixels on a s....

Who's Hiring

Author: Heubusch, Kevin

Source: Journal of AHIMA - website

Publication Date: October 2009

Kevin Heubusch


Oct 12, 2009 12:05 pm

In one sense, the future is already here for those who manage health information. The skills HIM professionals need today are not very different from those they’ll need in 10 years, according to a new survey of practitioners, recruiters,....

Fall Preview: A Look at the Season’s Expected Rules

Author: Heubusch, Kevin

Source: Journal of AHIMA

Publication Date: November 2011


Perhaps one of the biggest jobs related to implementing the ARRA provisions right now is keeping track of the moving parts. Publication of the act in 2009 was a kind of Big Bang-an explosion of provisions that rocked the healthcare universe. Since then, however, the pieces have traveled at dif....

On the Leading Edge in Long-term Care

Author: Heubusch, Kevin

Source: Journal of AHIMA

Publication Date: April 2008


Margie White started out as a nursing assistant in acute care. A brochure for AHIMA’s independent study program introduced her to HIM. She completed the program and applied for a job as medical record clerk in a long-term care facility.

And she kept going. White earned her RHI....

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