The move to an electronic record affects all areas of the hospital, and the release of information (ROI) function is no exception. In our first quarterly benchmarking survey of 2011, MRB examined the ROI practices of hospitals with hybrid or fully electronic records.
In what was perhaps an effort to remind providers to consider medical record retention as they move to EHRs, CMS released MLN Matters SE1022, which addresses medical record retention limits and media formats.
With the end of the year approaching, you, along with many of your HIM director and manager colleagues, may soon be tasked with conducting annual staff evaluations. Chances are it isn’t your favorite task of the year. But it needs to be done.
Present-on-admission (POA) indicators, hospital-acquired conditions (HAC), and never events have been around for a while. However, they still seem to cause compliance conundrums, says Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Marblehead, MA.
It should come as no surprise that medical record documentation made the list for top standards noncompliance for the first half of 2010. Our old favorites just won’t go away.
