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Medical Records Briefing

Issue 12, December 1, 2009 - VIEW THE FULL ISSUE

• Know these eight tips to ensure secure PHI

  HHS’ message is clear: Breaches of electronic protected health information (PHI) should not...

• Medical records yesterday, today, and tomorrow

  When I started working in a hospital in the mid-1960s, the medical record department still had huge...

• Know how an EHR could affect your accreditation survey

  When a surveyor comes knocking on your door, you had better have a plan in place that grants access...

• Begin budgeting now for the costly transition to ICD-10

  Do you ever wonder how much the transition to ICD-10 will cost? Individual hospital expenses are...

Issue 11, November 1, 2009 - VIEW THE FULL ISSUE

• Management matters

  Level of education is one of many factors that affect salary, and it continues to be one on which...

• HIPAA happenings

  The privacy and security changes pursuant to the Health Information Technology for Economic and...

• EHR beat

  EHR implementation is not simply on the to-do list at Health Quest, a three-hospital system in...

• Standards of the month

  Surveyors continue to cite hospitals for physicians’ failure to sign, date, and time entries...

Issue 10, October 1, 2009 - VIEW THE FULL ISSUE

• HIM directors' salaries on the rise, but profession isn't exempt from poor economy

  HIM director salaries are on the rise, according to HCPro’s MRB salary survey. Half of the...

• Understand changes for restraint and seclusion requirements to ensure survey success

  July 1 marked large-scale changes for hospitals that use The Joint Commission (TJC) for deemed...

• Six must-know tips for effective EHR implementation

  The cash incentives are available, but most HIM professionals know that EHR implementation is not...

• The EHR ‘spin zone’: Separating fact from fiction

  Healthcare reform, EHRs, quality initiatives, the underinsured, and clinical documentation...

• Use the 2010 IPPS final rule to lobby for more coder continuing education funds

  Many hospitals had feared a 1.9% reduction in payment for 2010, but they’ll actually see a...

Issue 9, September 1, 2009 - VIEW THE FULL ISSUE

• Illinois hospital ensures one-day stay compliance to avoid RACs

  The final phase of the national Recovery Audit Contractor (RAC) rollout began last month, and...

• Understand the HIM director?s role in the transition to HIPAA 5010

  A hospital’s information technology project list is likely exponential.

• What's the accuracy of your POA indicators?

    Just because coders have been reporting the present-on-admission (POA) indicator for nearly...

• Provide accurate and knowledge-based information at your facility

  IM.03.01.01: Knowledge-based information Unlike standards now in the RC chapter of the...

Issue 8, August 1, 2009 - VIEW THE FULL ISSUE

• Survey watch: Sign, date, time: The HIM director’s continuing quest for compliance

  Obtaining physicians’ signatures on their orders usually isn’t difficult. Asking them...

• HIPAA happenings: Privacy and security breaches: Make your sanctioning message loud and clear to ensure compliance

  Covered entities (CE) and business associates (BA) are not required to follow HHS guidance...

Issue 7, July 1, 2009 - VIEW THE FULL ISSUE

• Management matters: Eight essential questions every HIM director should ask about RAC record requests

  How many record requests can HIM directors expect to receive now that the permanent Recovery Audit...

• Lifetime EHR for veterans should serve as national model for longitudinal record, experts say

  When Deb Howard, 42, of Kingwood, TX, was discharged from the military in 1992, she received eight...

• What’s your EHR pre-implementation plan?

  We all have good EHR intentions—plans to pick out a system, hire a consultant, and go live...

• Survey watch: H&Ps continue to cause headaches for HIM directors

  Obtaining a timely history and physical (H&P) remains a constant challenge for most HIM...

• EHR beat: Understand ‘meaningful use’ to prepare for HHS definition, EHR incentives

  The amount is colossal: $4,896,450. This is the total maximum payment for which Mission Hospital...

Issue 6, June 1, 2009 - VIEW THE FULL ISSUE

• Illinois health system shares its EHR success story to help others obtain physician buy-in

  Terri Bunsen, chief privacy officer at NorthShore University HealthSystem in Evanston, IL, says...

• HIM job market remains promising for new grads in light of national focus on health IT

  It was only by chance that Beth Kost-Woodrow, RHIA, assistant vice president and chief privacy...

• Understand the requirements for the privacy, security, and integrity of health information: IM.02.01.01 and IM.02.01.03

  Although the privacy, security, and integrity of health information have not been subjected to...

Issue 5, May 1, 2009 - VIEW THE FULL ISSUE

• HITECH Act to stimulate EHR adoption, alleviate costly implementation

  The average cost of an EHR implementation in a large academic medical center or multihospital...

• Ten tips to successfully scan your way to an EHR

  When should you start scanning? Should you scan on-site? How many full-time staffers do you need to...

• Crack down on unauthorized uses and disclosures with your EHR?s audit log

  If you’re thinking about taking advantage of the incentive payments under the American...

• Make medical identity theft prevention a top priority

  Medical identity theft is an ugly reality for healthcare organizations, patients, and payers...

• ICU documentation is critical: Reflect patient severity to get credit where credit is due

  Understand the definition of critical care There are two general functions that we perform in an...

Issue 4, April 1, 2009 - VIEW THE FULL ISSUE

• Consider these six tips to ensure Joint Commission compliance in 2009

  You’ve conducted countless mock surveys, made important changes to enable process...

• Countdown to ICD-10: Devise a four-year training plan

  Although coders need not put their nose to the ICD-10 grindstone for another few years, that...

• Seven simple steps to effectively staff your coding department

  As an HIM director or coding supervisor, I’m sure you’ve been asked this question...

• Ensure compliance with IM.01.01.03 before a disaster or other emergency strikes

  Editor’s note: This column continues our series of articles for 2009 regarding The Joint...

• MRB benchmarking survey: HIM directors share scanning productivity standards

  Editor’s note: This article is the first in a two-part series on MRB’s scanning...

• Baby, it?s COLD outside: Consider these 12 tips to heat up your document management strategy

  Now that April is here, we no longer have to worry about ice, snow, and freezing rain. But when I...

Issue 3, March 1, 2009 - VIEW THE FULL ISSUE

• ICD-10 in 2013: Will you and your staff be ready?

  The news is out: October 1, 2013, is the deadline by which HIM directors must diligently spearhead...

• Prevent unintended consequences when rolling out computerized physician order entry

  Computerized physician order entry (CPOE) can increase physician efficiency and enhance patient...

• Joint Commission makes changes to maintain deeming authority with CMS

  Editor’s note: This column continues our series of articles for 2009 regarding The Joint...

• Prove return on investment to reap CDI rewards

  Implementing a clinical documentation improvement (CDI) program can have long-lasting benefits if...

• HIPAA refresher: Faxing PHI, retaining patient e-mails, using whiteboards, and more

  Editor’s note: Encourage staff members to review HIPAA guidelines by testing their knowledge...

Issue 2, February 1, 2009 - VIEW THE FULL ISSUE

• Know how the EHR could reshape your department and job

  It’s every HIM director’s dream: a relatively seamless EHR implementation that leads to...

• Confront ROI challenges: Proceed with caution in situations involving sensitive conditions

  Sensitive scenarios require extra attention when releasing protected health information. Ensure...

• AHIMA practice brief provides general ROI guidance

  When it comes to release of information (ROI), there is no one-stop shop that provides HIM...

• Comply with IM.01.01.01 as information flows throughout your organization

  by Jean S. Clark, RHIA This column continues our series of articles for 2009 regarding The Joint...

• Updated CoP reflect privacy, security, EHRs, and more

  EHRs, patient safety, privacy, and security are among the common themes in official updates to the...

• Understand how your EHR or hybrid record may affect Joint Commission compliance

  Your to-do list in 2009 will probably remain relatively unchanged, with several tried-and-true...

Issue 1, January 1, 2009 - VIEW THE FULL ISSUE

• Benchmarking survey: PHRs remain unchartered territory for some

  Personal health records (PHR) can literally change the world. Sound a bit lofty? Kerry Weems...

• Ensure a plan for legal holds during an EHR transition

  As more hospitals implement a hybrid record as they transition to a complete EHR, the once fairly...

• One health system implements a patient portal as a first step toward a fully integrated PHR

  Care New England, a three-hospital system in Rhode Island, was familiar with the acronym PHR...

• Understand the myth of the paperless record

  Is a paperless medical record department truly possible? Architects who design new healthcare...

• Understand new Joint Commission scoring systems, symbols, and chapters for 2009

  by Jean S. Clark, RHIA Editor’s note: This column introduces our series of articles for 2009...

• Form a RAC response team before it's too late

  These days, the words “recovery audit contractor” (RAC) are on every HIM...

• Take ownership of patients’ background health risks

  We all do a great job in documenting our patients’ history and physical exams. We all...