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Displaying records 1 to 20 out of 2854 results for "EHR downtime documentation".
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SORT RESULTS BY: RELEVANCY | PUBLICATION DATE
With the use of EHRs on the rise, so too is inappropriate use of EHR functionality. Many of these
Stage 1 of the EHR Incentive Programs focuses on capturing and sharing data and Stage 2 focuses o
The Association of Clinical Documentation Improvement Specialists (ACDIS) released a new position
NOVEMBER 5, 2014
Advancements in electronic health records (EHR) have improved nursing documentation and patient s
JANUARY 26, 2017
The electronic document management system (EDMS) plays a role in designing the official legal h
The deadlines for reporting certain 2016 electronic health record (EHR) data for the
Find out how one facility created an electronic health records (EHR) solution to improve m
MAY 20, 2015
JUSTCODING
  Medicaid EHR Q&A
DECEMBER 22, 2017
Logic says that electronic health records (EHR) should be a huge boon to healthcare quality. Up-t
NOVEMBER 1, 2016
In the age of electronic health records (EHR) and value-based purchasing, accurate and complete
JULY 7, 2016
Using a streamlined approach to EHR documentation may help reduce stress for resident, according
AUGUST 7, 2015
Q&A: What makes a quality EHR? Editor’s note: A 2016 study
Many electronic health record (EHR) systems still have issues with importing inaccurate informati
MARCH 18, 2015
When selecting an EHR vendor, don’t forget the add-ons!
Logic says that electronic health records (EHR) should be a huge boon to healthcare quality. Up-t
NOVEMBER 8, 2016
Q: Can you tell me whether there is a resource that lists documents and required retentio
  Why are physician queries so critical to accurate documentation and coding? The an
"EHRs are a great idea. But we should have allowed the market to convince physicians of th
SEPTEMBER 11, 2014
The ease of copy-and-paste and lack of guidance from CMS regarding electronic health records (EHR
EHR adoption has been a slow process as physicians struggle to see its effects on patient care. H
“It’s time to stop calling them EHRs.  Yes—we also need to stop calling th
HIM Briefings is conducting a benchmarking survey on EHR operationalization and
FEBRUARY 21, 2017
A proposed CMS change to the 2017 Medicare Physician Fee Schedule will require surgeons document
SEPTEMBER 13, 2016
Q: Our physicians document a diagnoses of pneumonia but do not normally make a specific
APRIL 9, 2014
JUSTCODING
The use of electronic health records (EHR) should be guided by ethical principles that put patien
EHRs are vulnerable to fraud despite the existence of tools to prevent and combat fraud and abuse
We all know that ICD-10 codes will require more complete documentation. We’ve been t
Electronic health records (EHR) have slowly made their way into long-term care (LTC), with
DECEMBER 23, 2016
Despite the many promises to the otherwise, electronic health records (EHR) haven’t simplif
SEPTEMBER 20, 2016
A recent poll on the ACDIS website seems to show that electronic health record (EHR) implementati
After anecdotes that electronic health records (EHR) cause upcoding, Julia Adler-Milstein of the
Updates for 2015–2017 to the EHR Incentive Program caused some providers to questions wheth
EHRs and other health IT could help physicians ensure their patients take medications correctly
EHR menu design may influence provider decision-making  
APRIL 9, 2014
JUSTCODING
The American Medical Association (AMA) addressed weaknesses in CMS’ EHR Incentive Programs and
As helpful as electronic health record (EHR) systems may be, physicians say headaches due to gove
  The CMS EHR Incentive Program 2014 attestation deadlines for Medicare-eligible h
As electronic health records (EHR) become more prominent, healthcare organizations should search
How does working in your electronic health record (EHR) compare to using paper records?
APRIL 15, 2015
JUSTCODING
How does working in your electronic health record (EHR) compare to using paper records?
APRIL 8, 2015
JUSTCODING
How does working in your electronic health record (EHR) compare to using paper records?
MARCH 25, 2015
JUSTCODING
  While overall electronic health record (EHR) adoption is up nationally, many phy
The AMA is encouraging physicians to share their stories about their experiences with EHRs and M
JULY 30, 2015
OCTOBER 8, 2014
JUSTCODING
Documentation Documentation
NOVEMBER 13, 2013
JUSTCODING
As EHRs become more prominent, healthcare organizations should search for the best ways to levera
Do you have questions about physician practice coding, reimbursement, safety, EHRs, compliance, H
Some patients being cared for in a fully electronic health record (EHR) environment were less lik
Copying and pasting information in EHRs is a common practice that can save busy physicians and ot
Copying and pasting information in electronic health records (EHR) is a common practice that can
APRIL 5, 2016
As helpful as technological advances offered by electronic health record (EHR) systems may be, ph
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician document
SEPTEMBER 3, 2014
JUSTCODING
  Dear readers,   Electronic health records (EHR) con
SEPTEMBER 18, 2014
The American Medical Association (AMA) and a group of major EHR vendors pledged to work with HHS
Most medical students use EHRs to track former patients, according to a study published in JA
JULY 29, 2016
  Documentation standards
JANUARY 1, 2015
Do you have questions about physician practice coding, reimbursements, safety, EHRs, compliance,
Do you have questions about physician practice coding, reimbursement, safety, EHRs, compliance, H
Is your EHR on the right track? That’s the question a new poll on the ACDIS website aims to
APRIL 22, 2015
JUSTCODING
APRIL 29, 2015
JUSTCODING
Physicians have an array of EHRs and other health IT (HIT) products to choose from, but picking t
MARCH 25, 2015
JUSTCODING
The latest rules proposed this spring for the electronic health records (EHR) incentive programs
An Indiana-based EHR vendor and its subsidiary company were the victims of a sophisticated
An Indiana-based EHR vendor and its subsidiary company were the victims of a sophisticated
A fraud settlement by a major electronic health record (EHR) vendor with the Department of Justic
  Q&A: Documentation for body mass index
  Skilled Services: How to document for proper reimbursement
OCTOBER 9, 2015
  Featured member resource: ADR appeal documentation checklist
NOVEMBER 16, 2018
SEPTEMBER 24, 2014
JUSTCODING
Documentation of terminal illness at admission and during the hospice service period must be deta
Documentation of terminal illness at admission and during the hospice service period must be det
To accurately interpret and code physician documentation, the HIM department should employ
JUNE 4, 2014
JUSTCODING
  Have a question? Need to find a document? Not sure where to look? Watch this site demo now!
JANUARY 19, 2017
Can the plan of care serve as a way to document medications?  
What documentation is necessary for a medication review? The regulation
 Documentation
MARCH 11, 2015
JUSTCODING
Q: Our EHR system only provides for a "yes/no" choice under smoker. How can we
Effective documentation of the condition and the patients’ co-morbidities may help lawyers
In December 2014, CMS posted a document on its Advisory Panel on Hospital Outpatient Payme
Incomplete documentation in patient clinical records can cause your organization legal and settle
SEPTEMBER 18, 2019
Medical staffs across the country are discovering their governance documents are inadequate for t
In the scenario you discuss, your agency’s billing department reviews documentation before
  A Comprehensive Error Rate Testing (CERT) study found insufficient documentation
JULY 22, 2015
JUSTCODING
Now in its second edition, documentation-improv
APRIL 9, 2014
JUSTCODING
Now in its second edition, documentation-improv
JUNE 4, 2014
JUSTCODING
Now in its second edition, documentation-improv
AUGUST 13, 2014
JUSTCODING
Become more proactive. You no longer can wait for face-to-face documentation to arrive within sev
As the use of electronic health records (EHR) surges and organizations work toward meaningful use
Insufficient documentation is the leading cause of improper payments for claims involving referri
OCTOBER 28, 2015
JUSTCODING
 Although documentation matters more and more in today?s world of ever-changing regulations, med
AUGUST 4, 2017
Q: I’m in a little debate: Does documentation of the patient’s body mass in
MAY 7, 2014
JUSTCODING
Providers don’t often receive education on clinical documentation, which can be a challenge
In a recent frequently asked questions (FAQ) document released by the Centers for Medicare &
ACDIS, the Association of Clinical Documentation Impro
APRIL 7, 2011
Q&A: Managing LS, EC, and EM documentation Editor
DECEMBER 20, 2016
Q: Can you code strictly from emergency department (ED) documentation? Can you code from tes
DECEMBER 16, 2015
JUSTCODING
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
JANUARY 19, 2016
The Association of Clinical Documentation Improvement Specialists (ACDIS), the premier healthcar
SEPTEMBER 10, 2012
An outpatient clinical documentation improvement (CDI) program should be aligned with a fa
Proper documentation is critical when it comes to supporting medical necessity and providing qual
What should our clinicians document if the patient hasn't had the flu vaccine yet? The pa
Is it true that the following documentation is an improper certification statement on our
There has been a fair amount of coverage on the documentation requirements needed to assign ICD-1
The focus for clinical documentation improvement (CDI) specialists has historically been on the i
FEBRUARY 21, 2017
by Kirsten Dize Make completing documentation in the home a requirement for all
Coding and documentation should tell a patient's complete story. With the greater specific
  Medical staffs are discovering their governance documents are inadequate for tod
SEPTEMBER 18, 2014
Insufficient documentation led to approximately 97% of improper payments for kyphoplasty a
JULY 23, 2014
JUSTCODING
At ACDIS, it’s no surprise when we hear about clinical documentation improvement efforts
Take a close look at the documentation guidelines that CMS suggests for the practice improvement
The first Clinical Documentation Improvement Week is taking place from September
SEPTEMBER 21, 2011
ACDIS, the Association of Clinical Documentation Improvement Specialists, the leading national as
FEBRUARY 8, 2011
by Kirsten Dize Strong documentation is key in home health, and implementation o
Measure a wound from inside edge to inside edge to correctly document wound size, and ensure that
We have been told that the following documentation would position us for a potential clai
The Association of Clinical Documentation Improvement Specialists (ACDIS) last week updated its
OCTOBER 13, 2015
By utilizing the information documented in the record, coders can report the BMI from a dietitian
The documentation surrounding your QAPI program should include:  
MAY 21, 2014
JUSTCODING
Q: Is the statement “please document in a progress note to capture the severity of i
Clinical documentation is often overlooked during residency, yet without proper training, new ph
SEPTEMBER 9, 2016
In recent years, hospitals have increasingly focused on creating clinical documentation improveme
New EP: Avoid RFIs by keeping documents and service manuals in library “If it was
JANUARY 1, 2018
New EP: Avoid RFIs by keeping documents and service manuals in library “If it was
DECEMBER 1, 2017
Documentation: Getting the details right Joint Commission eli
DECEMBER 6, 2016
HCPro, Inc., and ACDIS, the Association of Clinical Documentation Improvement Specialists, today
JUNE 15, 2011
Nurses new to home health struggle with the completion of documentation related to patient care.
CMS doesn't require Medicare Advantage plans to have a face-to-face document for home health. Bu
No. The regulations do not mandate any particular form or format for documentation or confirmati
Q: Can you clarify the expectations related to documenting the discussion betwee
Q: In terms of coding blood transfusions, does the documentation of which intravenous (IV)
APRIL 23, 2014
JUSTCODING
Q: I am a coder in a hospital outpatient setting. Our physicians document drug use in s
JULY 22, 2015
JUSTCODING
Documentation will be important to support supply utilization and payment. Claims
Regardless of the clinical background of those responsible for reviewing documentation, it can be
It’s an age-old question: How do you get physicians to support documentation improvement ef
ACDIS, the Association of Clinical Documentation Improvement Specialists
AUGUST 1, 2012
Documentation example for coders in
OCTOBER 29, 2014
JUSTCODING
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician document
  Q: Is it okay to code a diagnosis if the physician documents two diagnoses usin
SEPTEMBER 24, 2014
JUSTCODING
By James S. Kennedy, MD, CCS, CDIP The physician documented “encephalopathy&
MARCH 25, 2015
JUSTCODING
Documentation example in
MARCH 4, 2015
JUSTCODING
The Certified Clinical Documentation Specialist (CCDS) exam hit a pretty big milestone last weeke
If you feel pretty confident as an agency that your documentation can pass muster and the totalit
The St. Louis County Health Department recently discovered that a document containing PHI was ema
MARCH 11, 2015
JUSTCODING
JULY 22, 2015
JUSTCODING
"[A]s we enter into clinical practice, physicians face the burdens of documentation and reg
SEPTEMBER 17, 2015
SEPTEMBER 30, 2015
JUSTCODING
In the early days of clinical documentation improvement programs many staff members reported up t
The patient care plan (485) is not a stand-alone documentation system; it is the legal record of
Residency training typically serves as physicians’ first exposure to the clinical document
AUGUST 11, 2017
Documenting medical necessity has become a big topic over the last several years and there has be
MARCH 22, 2019
Finding effective ways to continuously remind physicians of documentation improvement methods can
Finding effective ways to continuously remind physicians of documentation improvement methods can
Focus on documentation. CMS believes it is the responsibility of the homecare provider to attempt
NOVEMBER 20, 2013
JUSTCODING
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s pre
FEBRUARY 16, 2015
A patient comes into the ED following an automobile accident. The physician documents that the pa
SEPTEMBER 3, 2014
JUSTCODING
SEPTEMBER 23, 2015
JUSTCODING
Coders are tasked with telling a patient’s story based on the documentation in the m
MAY 20, 2015
JUSTCODING
Q: I am looking for documentation or physician education tips related to ventilator manage
by: Kirsten Dize CMS’ revised OASIS Q&A document offers welcome insight
The Association of Clinical Documentation Improvement Specialists (ACDIS) honored the nation&rsqu
MAY 25, 2016
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
FEBRUARY 9, 2015
A patient presents to the ED with a headache, nausea, and vomiting. The physician documented that
FEBRUARY 25, 2015
JUSTCODING
OCTOBER 8, 2014
JUSTCODING
Although documentation matters more and more in today’s world of ever-changing regulations,
AUGUST 4, 2017
Q: Is it okay to code a diagnosis if the physician documents two diagnoses using
ACDIS is proud to celebrate the 3,000th Certified Clinical Documentation Specialist (CCDS) creden
Q: When physicians continue to only document respiratory failure in the inpatien
JUNE 4, 2014
JUSTCODING
Incidents reports are a pain to fill out, but vital for documenting what happened and for pro
SEPTEMBER 10, 2015
NOVEMBER 20, 2013
JUSTCODING
The Medicare Payment Advisory Commission's documents/Mar14Entire
MARCH 21, 2014
In the budget document released by the Office of Management and Budget, the White House's propose
Friday, April 11 is the deadline to apply for the Certified Clinical Documentation Specia
NOVEMBER 26, 2014
JUSTCODING
Physician documentation for the use of osteogenic stimulators for nonunion of fractures is often
JANUARY 28, 2015
JUSTCODING
Need another reason to avoid billing denials by ensuring proper documentation? A new study in the
AUGUST 26, 2015
JUSTCODING
Q: I have seen documentation of oliguric renal failure and non-oliguric renal failure. What is th
OCTOBER 21, 2015
JUSTCODING
OCTOBER 14, 2015
JUSTCODING
Q: I have seen documentation of oliguric renal failure and non-oliguric renal failure. Wha
 It will depend a lot on documentation. This may be something to query. For example, even if
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
DECEMBER 30, 2015
ACDIS—the Association of Clinical Documentation Improvement Specialists—announced tod
MARCH 18, 2014
NOVEMBER 19, 2014
JUSTCODING
HCPro, Inc. and the Association of Clinical Documentation Improvem
Does your hospital have a clinical documentation improvement (CDI) program (i.e., a department, s
APRIL 23, 2014
JUSTCODING
Does your hospital have a clinical documentation improvement (CDI) program (i.e., a department, s
APRIL 30, 2014
JUSTCODING
MAY 14, 2014
JUSTCODING
New on JustCoding Platinum! New ICD-10-CM documentation examples in
JULY 9, 2014
JUSTCODING
Every provider has basic information he or she must document in the health record, says Lisa Ging
Take an in-depth look at coding, documentation, and querying for acute kidney injury (AKI). Durin
APRIL 8, 2015
JUSTCODING
Take an in-depth look at coding, documentation, and querying for acute kidney injury (AKI). Durin
MARCH 25, 2015
JUSTCODING
FEBRUARY 11, 2015
JUSTCODING
Incidents reports are a pain to fill out, but vital for documenting what happened and for pro
SEPTEMBER 3, 2015
In 2016, those sitting for the Certified Clinical Documentation Specialist (CCDS) exam face the b
The proof of medical necessity strictly relies on the MD documentation and diagnosis and the skil
SEPTEMBER 23, 2015
JUSTCODING
MAY 6, 2015
JUSTCODING
OCTOBER 22, 2014
JUSTCODING
Q: The physician documented “encephalopathy” in the record of a patient who wa
Q: The primary physician documented subacute cerebral infarction and I am wondering whe
NOVEMBER 5, 2014
JUSTCODING
I’m always excited to read an article about clinical documentation improvement in the mains
The Association of Clinical Documentation Improvement Specialists (ACDIS) just launched a redesig
JUNE 20, 2016
The Association of Clinical Documentation Improvement Sp
OCTOBER 1, 2010
The Association of Clinical Documentation Improvement Specialists (
FEBRUARY 23, 2012
MARCH 19, 2014
JUSTCODING
ACDIS is preparing to draft its third incarnation of the popular The Physician Documentation I
APRIL 23, 2014
JUSTCODING
APRIL 30, 2014
JUSTCODING
MAY 7, 2014
JUSTCODING
JUNE 11, 2014
JUSTCODING
Knowing the bones of the feet, and ensuring they're being properly documented by providers
JULY 30, 2014
JUSTCODING
AUGUST 6, 2014
JUSTCODING
AUGUST 20, 2014
JUSTCODING
AUGUST 27, 2014
JUSTCODING
Documentation sample for coders in
NOVEMBER 12, 2014
JUSTCODING
Q: If a is patient admitted with malnutrition and the physician documented the patien
JANUARY 28, 2015
JUSTCODING
  Creating a new position to assume a physician’s documentation duties may l
APRIL 15, 2015
JUSTCODING
FEBRUARY 25, 2015
JUSTCODING
Click the PDF icon above to download. Included in this document:
MAY 13, 2015
JUSTCODING
JULY 15, 2015
JUSTCODING
While many case managers today work closely with clinical documentation improvement (CDI) special
JANUARY 5, 2016
On March 8, CMS posted a document in the Federal Register correcting technical and typog
Coding guidelines direct to code all documented conditions that exist at the time of the visit an
MAY 7, 2014
JUSTCODING
Q: We had a question regarding documentation in a record of SIRS due to acute peritonit
MAY 21, 2014
JUSTCODING
Q: When the surgeon documents excision of a complex pilonidal cyst with rhomboid flap c
JULY 8, 2015
JUSTCODING
NOVEMBER 11, 2015
JUSTCODING
Q: In the past few weeks, we noticed physicians are documenting acute conge
Q: If a physician documents sepsis due to decubitus ulcer and UTI due to indwelling catheter, c
Most coders and clinical documentation improvement (CDI) specialists are familiar with the Unifor
JANUARY 14, 2015
JUSTCODING
AUGUST 20, 2014
JUSTCODING
  When a provider fails to document whether a patient diagnosed with monoplegia ha
MAY 13, 2015
JUSTCODING
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
JANUARY 29, 2016
JUNE 18, 2014
JUSTCODING
JULY 29, 2015
JUSTCODING
MARCH 26, 2014
JUSTCODING
MARCH 5, 2014
JUSTCODING
We want physicians to be very clear in their documentation about what’s wrong with the pati
MAY 13, 2015
JUSTCODING
CMS posted updated versions of all the guidance documents posted on the
MARCH 26, 2014
JUSTCODING
Q: The primary physician documented subacute cerebral infarction and I am wondering whethe
SEPTEMBER 17, 2014
JUSTCODING