The CMS EHR Incentive Program 2014 attestation deadlines for Medicare-eligible hospitals and professionals draw near (November 30 and December 31, respectively), so MRB asked healthcare professionals to reflect upon their successes and struggles associated with EHR implementation for benchmark survey.
I have recently heard questions and discussion about the use of abbreviations within the medical record. With that in mind, this quarter's Joint Commission column will outline the requirements for abbreviations and provide guidance regarding the pros and cons of expanding the limited "do-not-use" list
Perhaps it's because I reside in Chicago?home of both Oprah Winfrey and the American Health Information Management Association?but lately I have been thinking about "aha moments" for HIM professionals.
Imagine the information services department manager tells the HIM director he or she can't outsource transcription or receive reports directly in the EHR without a tremendous amount of manual intervention.
CMS' fiscal year 2015 IPPS final rule focuses on quality initiatives mandated by the Affordable Care Act, including updates to the Hospital Value-Based Purchasing Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition Reduction Program. This quality focus creates a need for increased interdisciplinary collaboration across quality, HIM, risk management, revenue cycle, compliance, and technology.
There has been a fair amount of coverage on the documentation requirements needed to assign ICD-10-CM diagnosis codes. While changes in documentation requirements for pregnancy, coma, diabetes, fractures, and pressure ulcers are frequently cited, less information is available regarding the documentation requirements for procedures.