Electronic Health Record (EHR) Management and Legal EHR Resources

Movement to the EHR is embedded in federal legislation. Those working in health information management (HIM) and in health informatics (HI) are poised to lead the management of the EHR to this end, AHIMA supports HIM and HI with the following resources.

Communities
of Practice

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• Disaster Management 
• E-HIM®
• Enterprise Imaging
• HIM Professionals in IT Roles
• HIPAA: Computer-based Record

This growing professional network provides answers, support, and career advice using the latest technology. As a member of AHIMA, you may access the CoP by logging into myAHIMA. If you are not a member join now and take advantage of the CoP, and join the communities that best fit your needs.

Practice Briefs
& Tools

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 AHIMA Practice Briefs

• Managing Nontext Media in Health Practices 
• Problem List Guidance in the EHR
  
• Managing the Transition from Paper to EHRs
• Enterprise Content and Record Management for Healthcare
• Role of the Personal Health Record in the EHR (Updated)
  
• The RFP Process for EHR Systems (Updated)
• Migrating from Paper to EHRs in Physician Practice
• Fundamentals for Building a Master Patient Index/Enterprise Master Patient Index (Updated)
• EHR Adoption in LTC and the HIM Value
• Patient Access and Amendment to Health Records (Updated)

• Fundamentals of the Legal Health Record and Designated Record Set
• AHIMA Model E-Discovery Policies: Preservation and Legal Hold for Health Information and Records
• AHIMA Model E-Discovery Policies Retention, Storage, and Destruction and Electronic Health Information and Records
• AHIMA Model E-Discovery Policies: Production and Disclosure of Health Information and Records for E-Discovery
• Litigation Response Planning and Policies for E-Discovery
• EHRs as the Business and Legal Records of Healthcare Organizations (Updated)
  

AHIMA Toolkits

• Recovery Audit Contractor (RAC) Toolkit
• Amendments, Corrections, and Deletions in the Electronic Health Record Toolkit
• Copy Functionality Toolkit
• Electronic Signature, Attestation, and Authorship (Updated)

 AHIMA Body of Knowledge (BoK)

Publications

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 AHIMA Publications

• Managing Records between the EDMS and EHR (February 2011, Working Smart)
• Print Restrictions in the EHR (January 2011, Working Smart)
• Streamlining Patient and Physician Communication (November-December 2010, Working Smart)
• CPOE Lessons Learned (October 2010, Working Smart)
• Deleting Errors in the EHR (September 2010, Working Smart)

• "A Patient-Centric, Provider-Assisted Diabetes Telehealth Self-management Intervention for Urban Minorities"
• "Innovation in Indian Healthcare: Using Health Information Technology to Achieve Health Equity for American Indian and Alaska Native Populations"

 

External
Resources

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 External Resources

• The American Academy of Family Physicians’ (AAFP) Recommended Curriculum Guidelines for Family Medicine Residents: Medical Informatics. This guide outlines the informatics and computer competencies, attitudes, knowledge and skills that should be among the objectives of training programs in family medicine.


•  The HL7 Electronic Health Records Work Group's Home Page provides information related to the ongoing HL7's Electronic Health Record Systems standards development work, including downloadable files for the HL7 EHR system functional model and EHR interoperability standards. For more information on EHR standards and AHIMA’s involvement in those efforts, visit AHIMA’s Industry Standards pages.


• AHIMA endorses the Dictation Best Practices Tool Kit, compiled by the Association for Healthcare Documentation Integrity (AHDI). The Tool Kit is designed to assist facilities with the adoption and implementation of policies and training practices that will promote high quality dictation and ensure the best documentation outcomes. AHIMA staff members served as reviewers and editors of this product. AHIMA believes this product will be of use to the HIM industry including and beyond transcription and supports the effort to address the impact of problem dictation as it relates to documentation errors and critical flaws affecting patient safety, the potential for sentinel events, the effects on turnaround time, and the resulting increased cost.
   
  1. A Note from AHDI
  2. How to Use This Kit
  3. Dictation Best Practices 8 Minute Orientation
     
  4. Dictation Best Practices PowerPoint Presentation
  5. Presentation Handouts
     • Presenter’s Notes with Slides
     • Slides with Notes Area
  6. Dictation Best Practices Rationale
  7. Dictation 101
  8. Strategies for MTSOs
     
  9. Q Cards
  10. Tip Sheet
  11. Model Policies & Procedures


• AHIMA and the Association for Healthcare Documentation Integrity, as well as contributors from the Medical Transcription Industry Association, have collaborated to produce Healthcare Documentation Quality Assessment and Management Practices, a resource for establishing a comprehensive transcription QA program for healthcare organizations.