The Joint Commission's September 2015 Perspectives encourages "hospitals to design systems to ensure accurate and complete medical records." Although this is not a new concept, it becomes more important as more hospitals' medical records become electronic while still maintaining a certain amount of paper documentation.
As we embark on our 30th year of delivering you the latest in HIM, we would like to invite you to celebrate the HIM profession with us. Each month this year, HIM Briefings (formerly Medical Records Briefing) will include a special feature that highlights the changes to our publication and the HIM profession over the years.
Compliance with the 2-midnight rule can be tricky for many organizations, which has left many case managers with nagging questions about how to get it right. We got the following questions from our readers and asked two of our experts to weigh in.
HIM Briefings (formerly Medical Records Briefing) asked HIM and release of information (ROI) professionals about their ROI practices for its first quarterly benchmarking survey of 2016. (The survey was completed in October 2015.) We introduced several new questions this year about the medical record itself as well as ROI practices.
Providers often struggle with modifiers‑even those they've had available to report for many years‑due to the unique scenarios they face at their facilities, staffing changes, and/or unclear or lacking authoritative guidance.
