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....

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....

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.....

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.

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....

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....

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....

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....

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: 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.