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
In 2008, only 11% of respondents to an Association of Clinical Documentation Improvement Specialists (ACDIS) poll indicated their clinical documentation improvement (CDI) programs either reviewed outpatient records for documentation improvement opportunities or were looking to expand into outpatient areas (8% and 3% respectively).
Revenue cycle leaders, including HIM professionals, are aware that a patient billing or collection problem can destroy what had up to that point been an exceptionally positive clinical experience. With the ever-expanding reach of social media, a patient who is dissatisfied with a billing or collection problem may be more likely to share that problem with others rather than sharing private details about clinical problems.
Although HIM professionals do not treat or diagnose patients, their role in managing all the moving parts in a healthcare organization affects overall quality of care.
It's no secret that the scope of HIM is expanding, so one would assume that compensation for HIM directors and managers is on the rise but this may not be the case.
Provider-based clinics and departments are increasingly common at hospitals, but the rules for provider-based qualification and billing can often be confusing.
My column in the April MRB addressed unexpected disruptions for HIM managers and the importance of backup plans?quite timely because the ICD-10 implementation delay was announced just before the newsletter was published.
Implementing a patient portal is at the top of the list for many organizations working toward attestation for Stage 2 Meaningful Use of EHRs under CMS' EHR Incentive Programs.
As healthcare continues to evolve, addressing the effect changes may have on the healthcare landscape and establishing goals for the future is important.
