HCPro.com: Medical Records Briefing

Guiding Health Information Management professionals through the continuously changing field of medical records and toward a stronger process for fifteen years!

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April 2008 (Volume 23, Issue 4)	view entire issue

MRB benchmarking survey: Readers discuss ROI challenges
How many times has your HIM department faced one of these scenarios? A patient's husband presents to the hospital requesting copies of his wife's medical records. A parent requests a copy of her son's medical record. An attorney requests information for a court case. Medicare requests information about a beneficiary. The laundry list of scenarios in which a requester could potentially want access to protected health information is exponential. And although HIPAA and state laws provide guidance for when you can and can't release information, it isn't always black-and-white, and it differs from state to state.

Ensure that your remote coding program's security is up to par with CMS guidance and HIPAA
Devices and tools used to store and transmit electronic protected health information (ePHI), such as personal computers, flash drives, and remote access devices, are a source of growing concern at CMS. If your coders work remotely, now is the time to reexamine your security policies. In December 2007, CMS announced a contract with PricewaterhouseCoopers for the company to conduct security audits focusing on CMS' remote access guidelines released in 2006.

Think outside the box when it comes to EDMS
Electronic Document Management Systems (EDMS) have existed for many years and have served varying purposes during EHR implementation. Hospitals originally used an EDMS as a tool to replace alternative forms of record archival storage, such as microfilm, microfiche, or CDs. An EDMS allowed hospitals to scan paper documents into a database. As the EDMS evolved-and the use of Computer Output Laser Disk (COLD) electronic interfacing increased-it created the foundation for a legal health record. The refinement of EDMS features over the years led to improved work flow systems that began integrating application-specific functionality for HIM departments.

Consider these 12 tips for selecting an EHR vendor, effectively negotiating a contract
Selecting an EHR vendor can be overwhelming due to the number of options available in today's competitive market. And even when you've found the right vendor, negotiating a contract can prove to be difficult. Steven Henkind, MD, PhD, principal consultant with Cardinal Consulting in Larchmont, NY, offers the following tips to help you through the process.

Expect increased patient-driven amendments with EHRs
The HIPAA Privacy Rule (section 164.526) permits patients to amend their medical records, and as more hospitals move toward an EHR, patient awareness of this right is increasing. Patients are also becoming more astute with respect to information that physicians are documenting about their past and present medical history.

Quiz: Querying for the POA indicator
Instructions: Ensure that staff members know when it is appropriate to query for the present-on-admission (POA) indicator. Use the following scenarios to test their knowledge. Scenario #1: A physician admits a patient with acute systolic heart failure. The physician documents in the medical history that the patient has diabetes mellitus type 2, hypertension, and an old myocardial infarction.

Identify manifestations, probable underlying causes for altered mental status to capture patient severity
Dear colleagues: This month, we'll discuss documentation strategies for altered mental status (AMS), a commonly underdocumented condition for which greater specificity regarding manifestations and probable underlying causes will better substantiate patient severity of illness in pay-for-performance methodologies.

Other recently-published articles from Medical Records Briefing:

Make sure acute myocardial infarction data is correct before core measures catch up with you

Clean up your MPI before implementing an EHR

Salary survey: More responsibilities, little to no extra pay

Avoid leading queries despite lack of AHIMA guidance

Emphasize importance of coded data to prepare for proposed quality measure expansion

Review cataract coding guidelines to ensure compliance in honor of Cataract Awareness Month

Understand behavioral restraints, seclusions

Keep DNFB low in light of MS-DRGs, POA

The severity train is leaving the station

Prepare for the worst, hope for the best

Understand requirements for patient restraint and seclusion

Backlog, backlog, go away: Don’t come back another day

Ask these questions to define your legal health record

Choose wisely when hiring a CDI specialist

HIM directors discuss appealing RAC denials and tracking data

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