I was recently discussing the state of EHRs in regard to the poor quality of the documentation with a colleague who has been a practicing HIM professional for more than 35 years and currently works for a large group of hospitals as the coding director.
Having recently returned from teaching the HCPro Accreditation Specialist Boot Camp, I was reminded that our medical staffs continue to have challenges with documentation requirements that have existed at least as long as most of us have been HIM professionals. I thought it was a good time to remind HIM professionals and their medical staff of 12 documentation requirements that are still a major focus during Joint Commission surveys, and persist in being a record completion challenge.
Q: The company I work for has long debated what to do about medical records that are sent out on CDs. We concluded that since paper records could not be encrypted, we shouldn't have to worry about encrypting the CDs.
