News & Analysis

July 9, 2018
News & Insights

Our facility is looking into outsourcing our transcription. What should we consider before we make the leap?

July 6, 2018
News & Insights

On June 28, a woman from Butler, Pennsylvania, was indicted by a federal grand jury, accused of wrongfully obtaining and disclosing protected health information (PHI) in violation of HIPAA.

July 6, 2018
Case Management Monthly

Social determinants of health are social factors, such as homelessness, illiteracy, a history of childhood trauma, and joblessness or underemployment, that can affect a person’s health. Coding for these factors is important because CMS officials now use some of them to adjust quality measures for patients who are dual-eligible for Medicare and Medicaid, and coding these factors may help shape future health policy.

July 6, 2018
News & Insights

Q: Is it appropriate to query whether a pressure ulcer was present on admission (POA) if it was not documented until later in the admission?

July 5, 2018
News & Insights

Q: I work in a skilled nursing facility and would like to post the level of assistance needed and precautions on a dry erase board in patients’ rooms for nursing assistant use. Is this allowed?

July 4, 2018
HIM Briefings

Although regulatory agencies have not banned the use of medical scribes, organizations must follow certain requirements. Learn how to define the scribe’s role and responsibilities and ensure that documentation is correctly certified.

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