308 results.
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Assigning Secondary Codes from the History and Physical
Author: Bronnert, June
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: March 2006
To code or not to code can be one of the toughest questions a coder faces on a day-to-day basis. Assigning the appropriate secondary diagnoses can be a challenge. This article describes appropriate coding of secondary diagnoses by reviewing documentation of a history and physical.
Un....
Documentation Rx: Strategies for Improving Physician Contribution to Hospital Records
Author: Micheletti, Julie A.; Shlala, Thomas J.
Source: Journal of AHIMA
Publication Date: February 2006
Hospitals typically know which physicians need documentation therapy. However, they do not always have a comprehensive care plan. A combination of educational and operational steps can improve physician contributions in the documentation requirements for hospital records.
Identifying Iss....
Practice Toolkit: Medical Record Completion
Author: Hirsch, Ronald
Source: Journal of AHIMA
Publication Date: January 2006
Medical record completion compliance has always been a problem at Sherman Hospital, a medium-sized community hospital in Elgin, IL. The number of incomplete charts often exceeded the standard set by the Joint Commission on Accreditation of Healthcare Organizations, risking a type I violation.....
Maintaining a Legally Sound Health Record: Paper and Electronic
Author: E-HIM Work Group on Maintaining the Legal EHR
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: November 2005
This practice brief has been retired. It is made available for historical purposes only.
Documentation Improvement Initiative at Maimonides Medical Center, Brooklyn, NY
Author: Rivera, Madeline; Zusman, Irina; Kogan, Susanna; Sichalov, Nadia; Spector, Michelle
Source: AHIMA Convention
Publication Date: October 21, 2005
Summary
Maimonides Medical Center (MMC) in Brooklyn, NY, implemented a successful documentation improvement program in 2001. Under the auspices of the Case Management Department, documentation specialists, who are credentialed HIM professionals (RHIA, CCS), perform concurrent and....
Clinical Documentation Improvement Program Strategies
Author: Mills, Mary
Source: AHIMA Convention
Publication Date: October 21, 2005
Introduction
What Is CDIP?
Aclinical documentation improvement program (CDIP) is a program focused on improving clinical documentation on a concurrent basis where a coder or documentation specialist, such as a nurse, reviews the medical record and consults with physicians regarding....
Using Human Factors Engineering Concepts to Improve Documentation
Author: Booth, Julie Harmata
Source: AHIMA Convention
Publication Date: October 21, 2005
Introduction
Human factors engineering is the science of designing tools, tasks, information, and work systems to be compatible with the abilities of human users; this includes both physical and cognitive abilities. As a science, human factors engineering provides a framework to c....
Implementation of Documentation Enhancement Program at the Ohio State University Health System
Author: Osborn, Carol E.; Curtis, Elizabeth
Source: AHIMA Convention
Publication Date: October 21, 2005
Background
Of late, there has been much interest in the relationship between medical record documentation, coding, and the organization’s case-mix index (CMI). Many organizations have implemented documentation improvement programs with the goal of obtaining more specificity in codin....
Physician Order Entry Goes Online: the Effect on Records and HIM Operations
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....
Update: Guidelines for Defining the Legal Health Record for Disclosure Purposes
Author: AHIMA e-HIM Work Group on the Legal Health Record
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: September 2005
This practice brief has been retired. It is made available for historical purposes only.
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