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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May 2008 (Volume 23, Issue 5)	view entire issue

Don't let voluminous paper overwhelm you during the transition to an EHR
Imagining a time when medical records are simply a mouse click away may be difficult-especially when you're surrounded by endless stacks, files, or even entire rooms full of paper charts. Determining how to handle paper records during the transition to an EHR is a challenge for many hospitals, and a task that can intimidate even the most prepared HIM director. "The question is really from a policy perspective. How do you want to provide access to those records for physicians or other staff?" says Heidi Echols, chair of the Health Information Technology Affinity Group at McDermott Will & Emery, LLP, in Chicago. "Do you want to retain two sources of records or not?"

Ensure record completion for end-of-life care, resuscitation
Editor's note: This column is a continuation of our series about standards outside of the "Information Management" chapter in the Comprehensive Accreditation Manual for Hospitals that have documentation implications. Clark is the HIM service line director at Roper St. Francis Healthcare in Charleston, SC, and author of Information Management: The Compliance Guide to The Joint Commission Standards, Fifth Edition, published by HCPro.

Consider these 10 tips for conducting employee evaluations
For new HIM directors, conducting employee evaluations may be the most daunting task. Unlike seasoned directors, novice directors are still learning their job responsibilities along with employee names and faces. MRB asked several HIM professionals for tips on conducting fair employee evaluations, asking questions that will encourage productive dialogue, and implementing strategies to solicit employee feedback throughout the year-not just on evaluation day.

CMS releases revised Interpretive Guidelines for hospital CoPs
On February 8, CMS issued revised Interpretive Guidelines for hospital Conditions of Participation (CoP) that provided long-awaited clarification regarding history and physicals (H&P), timing/dating and authenticating entries, verbal orders, and postanesthesia evaluations addressed in the November 27, 2006, Federal Register. The guidelines, which take effect immediately, also reflect changes incorporated into the 2008 Outpatient Prospective Payment System regulations that clarify the time frame requirements for H&P exams and postanesthesia evaluations.

Severity of illness: What is it all about and what does it mean for physician profiles, public perception?
In the past several years, hospital staffs and insurance companies have bombarded all of us with medical necessity questions. Well, there's a new sheriff in town, and its name is severity of illness (SOI). It describes the seriousness of our patients' illnesses and the risk of adverse outcome to treatment choices. We may think of risk stratification as one way of determining which antibiotics to prescribe under certain circumstances. Or it may refer to whether a patient is a candidate for surgery, chemotherapy, or any other type of treatment. The Society of Thoracic Surgeons has produced a methodology for developing an SOI database so that its members can level the playing field and compare data with respect to mortality from chest cases.

Other recently-published articles from Medical Records Briefing:

Diabetes classification integral to hospital quality measurement, correct code capture

Address coder shortage with an apprentice program

Know requirements for sedation and anesthesia

Ensure that coders review the new ICD-9-CM coding guidelines effective October 1

Develop a plan for system downtime, slowness, and glitches

Ensure your place at the EHR decision-making table

Stress coding quality, understanding disease processes in light of the 2009 IPPS final rule

Education, credentials determine salaries

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

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