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
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.
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.
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.
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.
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).
