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Medical Records Briefing

Issue 12, December 1, 2008 - VIEW THE FULL ISSUE

• AHIMA’s final query practice brief reflects growing CDI efforts

  Coders and others who perform queries have waited seven years for AHIMA to update its 2001 practice...

• Electronic health IT advances create opportunities, challenges for HIM directors and staff members

  by John Healey, Esq. During the past three years, numerous legislative acts and regulatory rules...

• Requirements for patient discharge and transfer

  by Jean S. Clark, RHIA Editor’s note: This column is a continuation of our series on...

• How to code common winter ailments

  Scenario 1 A patient does not properly insulate her hands (i.e., wear gloves) while shoveling her...

• Put a stop to stamped signatures once and for all

  If you didn’t receive the memo about signature stamps, look no further than special edition...

Issue 11, November 1, 2008 - VIEW THE FULL ISSUE

• Knock, knock! Who’s there? It’s ICD-10, and you’d better be ready

  When someone says ICD-10, most HIM professionals roll their eyes and wait for the punch line.

• HIPAA: Transcription, breaches, and PHI for research

  Q. May a transcriptionist type a medical report pertaining to a visit between the physician and a...

• Ask what leadership means, and use self-assessment to pinpoint strengths and weaknesses

  Your leadership skills are invaluable when you’re implementing an EHR or overseeing any other...

• Understand the details of personal health records to serve as a valuable patient resource

  This scenario is becoming increasingly common: A patient presents to the HIM department and...

• Flag identity theft as federal rule takes effect

  Although identity theft is often associated with exploited credit cards, patients can also be...

• Polish your profile by clarifying heart failure, pneumonia, and pressure ulcers

  As many of us know, various staff members regularly approach us to address the quality of care we...

Issue 10, October 1, 2008 - VIEW THE FULL ISSUE

• Education, credentials determine salaries

  It should come as no surprise: Education and credentials can significantly increase earning...

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

  CMS released its IPPS final rule July 31 for fiscal year (FY) 2009, and HIM directors can expect a...

• Ensure your place at the EHR decision-making table

  There are leaders and there are followers. And during the labor-intensive process of an EHR...

• Develop a plan for system downtime, slowness, and glitches

  “The system is down” are four words no HIM director ever wants to hear.

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

  Instructions: Effective October 1, coders must refer to the newest set of ICD-9-CM coding...

• Know requirements for sedation and anesthesia

  The standards discussed in this article have been around for a long time; however, they continue to...

• Address coder shortage with an apprentice program

  Recruiting and retaining qualified coders is a never-ending challenge for HIM directors.

• Diabetes classification integral to hospital quality measurement, correct code capture

  Every year, the government updates the ICD-9-CM codes we use to report illnesses.

Issue 9, September 1, 2008 - VIEW THE FULL ISSUE

• Salary survey: More responsibilities, little to no extra pay

  Editor's note: This article is the first in a two-part series on the results of HCPro's annual MRB...

• Clean up your MPI before implementing an EHR

  HIM directors concur-duplicate medical record numbers are extremely difficult to manage. Correct...

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

  We are all aware of the practice guidelines for acute myocardial infarction (MI) because we've been...

Issue 8, August 1, 2008 - VIEW THE FULL ISSUE

• Keep DNFB low in light of MS-DRGs, POA

  Most HIM directors probably cringe when they think about their discharge-not-final-billed (DNFB...

• Understand behavioral restraints, seclusions

  Editor's note: This column is a continuation of our series on standards outside of the "Information...

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

  A cataract occurs when clouding develops in the eye's lens, causing light obstruction that...

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

  Editor's note: This article went to press before CMS published its 2009 IPPS Final Rule that could...

• Avoid leading queries despite lack of AHIMA guidance

  Editor's note: This article went to press before AHIMA published the final draft of its physician...

Issue 7, July 1, 2008 - VIEW THE FULL ISSUE

• HIM directors discuss appealing RAC denials and tracking data

  Editor's note: This is the second article in a two-part series in which HIM directors in three...

• Choose wisely when hiring a CDI specialist

  Editor's note: The following is an excerpt from HCPro's book The Clinical Documentation Improvement...

• Ask these questions to define your legal health record

  Unlike clothing, "one size fits all" is not an option when defining a legal health record (LHR...

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

  HIM consultants often encounter backlogs long after they have spiraled out of control, causing an...

• Understand requirements for patient restraint and seclusion

  Editor's note: This column is a continuation of our series on standards outside of the "Information...

• Prepare for the worst, hope for the best

  Most HIM directors think a disaster will never occur at their hospitals. And although channeling...

• The severity train is leaving the station

  We have experienced a fury of changes recently, including an increased focus on patient care and...

Issue 6, June 1, 2008 - VIEW THE FULL ISSUE

• Recovery audit contractors: Learn from your peers

  Editor's note: This is the first in a two-part series in which HIM directors in three RAC states...

• Callers continue to ask questions about RAC preparations

  If you have questions pertaining to recovery audit contractors (RAC), you're not alone. HCPro...

• Coding common summertime ailments: Review guidelines for allergic reactions, sunburns, and more

  Instructions: Encourage staff members to review these common coding scenarios that involve...

• Don't make a hasty decision when selecting an EHR vendor

  A hasty EHR vendor selection can lead to frustration at best or a failed implementation at worst...

• Stage pressure ulcers: specify origin and location so coders can reflect patient severity and assign proper codes

  Dear colleagues: The fiscal year 2009 Inpatient Pro-spective Payment System proposed rule...

Issue 5, May 1, 2008 - VIEW THE FULL 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...

• 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...

• Consider these 10 tips for conducting employee evaluations

  For new HIM directors, conducting employee evaluations may be the most daunting task. Unlike...

• CMS releases revised Interpretive Guidelines for hospital CoPs

  On February 8, CMS issued revised Interpretive Guidelines for hospital Conditions of Participation...

• 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...

Issue 4, April 1, 2008 - VIEW THE FULL 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...

• 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...

• Think outside the box when it comes to EDMS

  Electronic Document Management Systems (EDMS) have existed for many years and have served varying...

• 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...

• Expect increased patient-driven amendments with EHRs

  The HIPAA Privacy Rule (section 164.526) permits patients to amend their medical records, and as...

• Quiz: Querying for the POA indicator

  Instructions: Ensure that staff members know when it is appropriate to query for the...

• 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...

Issue 3, March 1, 2008 - VIEW THE FULL ISSUE

• HIPAA privacy and security audits: What you need to know to prepare

  Although covered entities (CE) have known that CMS would eventually enforce the HIPAA security rule...

• Callers seek clarification during POA listening session

  Hospital and other healthcare professionals had an opportunity to voice their opinions and ask...

• Consider these six reasons to enable a switch to e-prescribing

  As more healthcare organizations focus on reducing medical errors, more physicians are considering...

• Document plan of care, patient education

  This column is a continuation of our series of articles about standards outside of the Information...

• Employ an MPI clerk to control duplicate medical record numbers, clean up your MPI

  Most organizations have experienced the frustration of dealing with duplicate medical record...

• Know critical care billing, documentation requirements

  Physicians who take chances by skirting ethics to increase their revenue risk massive financial...

Issue 2, February 1, 2008 - VIEW THE FULL ISSUE

• Convey EHR benefits to get physicians on board

  When Sun Health, a nonprofit, community-owned network of healthcare services in Sun City, AZ...

• Case study: One hospital monitors its H&Ps to set benchmarks, significantly reduce the delinquency rate

  Many hospitals will admit that obtaining timely history and physicals (H&P) is no easy task. But...

• Address documentation requirements for emotional and behavioral disorders, diagnostic services, and care planning

  This column is a continuation of our series of articles about The Joint Commission's (formerly...

• Consider front-end speech recognition to reduce transcription turnaround time, improve documentation quality

  As hospitals begin the arduous transition to EHRs, many are striving to find ways to make the...

• Follow the MUSIC to ensure proper documentation

  Dear colleagues: Now that Medicare Severity DRGs (MS-DRG) are in their fifth month, most...

Issue 1, January 1, 2008 - VIEW THE FULL ISSUE

• Health information exchanges on the rise to share data, improve care

  In today's world of heightened privacy and security, a request to share personal medical...

• Educate staff about assessments for addictions

  This column continues our series of articles about The Joint Commission (formerly JCAHO...

• What's in a name: Healthcare IT's addiction to acronyms

  The following text comes from the National Alliance for Health Information Technology (NAHIT) Web...

• OIG Work Plan to investigate CMS' policies regarding The Joint Commission hospital accreditation process

  This year's Office of Inspector General (OIG) Work Plan, released October 1, 2007, includes at...

• Don't shoot the messenger when it comes to quality documentation and reporting

  I've said it many times before: We're in an information age, and we're in the "business of...