While it can be challenging to define your organization's legal health record (LHR), one health system in Denver is proving that collaboration and perseverance can lead to an effective LHR and EHR.
Coding and documentation should tell a patient's complete story. With the greater specificity in ICD-10, organizations should be better able to capture these stories, and the respiratory codes, listed in Chapter 10: Diseases of the Respiratory System (J00?J99), are no exception.
More than ever before, HIM is being recognized as an enterprise profession important to ambulatory, acute, and postacute settings. A good example of the transformation is HIM's involvement in CMS' risk adjustment and Hierarchical Condition Category coding system.
As the use of electronic health records (EHR) surges and organizations work toward meaningful use attestation, more in-depth monitoring of electronic patient records is becoming increasingly necessary.
