MRB asked HIM and release of information (ROI) professionals about their ROI practices for its first quarterly benchmarking survey of 2015. (The survey was completed in October 2014.) Half of survey respondents are HIM directors or managers (52%). Other respondents identified themselves as non-managerial HIM staff members (18%) or ROI directors or managers (4%). The majority of respondents (65%) work in hospitals.
RC.01.01.01, Content of the Medical Record, did not top the list of the survey findings for hospitals in the first half of 2014, according to the September 2014 issue of Joint Commission Perspectives. Nor was it on the list for critical access hospitals at all! However, 49% of hospitals surveyed received a requirement for improvement for this standard, primarily in the EPs related to timing and dating entries. This indicates hospitals are still using a lot of paper records. That said, the downward swing is encouraging as more and more hospitals fully implement the EMR.
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.
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.
Although numerous privacy and security laws apply to healthcare entities, HIPAA rules and requirements tend to receive the most emphasis?and generate the most angst. The terms HIPAA-compliant vendor, HIPAA cop, and HIPAA disciplinary action are anathema to experienced and serious privacy and information security professionals. HIPAA, as has been noted, represents the floor of requirements intended to protect the privacy and security of patient information. More stringent privacy requirements have existed at the state and national levels for several years before the HIPAA Privacy Rule was implemented (e.g., state medical records laws and requirements). Notably, many organizations implement policies and procedures that are more stringent than that required by HIPAA. Some of this is due to misinformation or misunderstanding of the HIPAA rules.
Q: If someone calls a facility to schedule an appointment for a patient, is it a violation of HIPAA to admit the patient receives care at the practice? For example, the practice where I work often helps victims of domestic abuse.
