AHIMA Practice Briefs provide practical and consensus-based guidance on traditional health information management (HIM) principles and evolving e-HIM®functions. Through research and professional volunteer efforts this best practice guidance is offered to AHIMA members and the healthcare industry as a resource for achieving our vision for quality healthcare through quality information. The practice briefs are organized by the topics below to help you more easily identify useful guidance.
AHIMA has also assembled a wealth of practice tools to assist our members and the healthcare industry in achieving our vision for quality healthcare through quality information. The following types of practice tools provide a world of important HIM practice information at your fingertips:
The AHIMA Leadership Models for E-HIM® provide a comprehensive framework and suite of tools that both educate and guide HIM professionals to visualize, initiate and lead specific HIM domain initiatives at institutional, regional, and national levels. The tools and techniques contained in the models aspire to help HIM professionals apply theory and technical knowledge using leadership techniques to drive institutions and the healthcare industry toward achieving the vision of e-HIM®.
The challenges associated with maintaining high quality data in electronic information environments require a clear understanding of data content standards and effective coordination and management of the organization’s data requirements. As experts in the management and use of health records and secondary data, HIM professionals should serve as the leaders in healthcare organizations and in their professional community for ensuring that data content standards are identified, understood, implemented and managed.
The challenges associated with maintaining legally sound health records in the hybrid and electronic information environments require clear identification of the issues, re-thinking of traditional record and information management practices and development and application of new strategies for managing health information. As experts in the requirements for health records, HIM professionals serve as the leaders in healthcare organizations and in their professional community for ensuring that such requirements are identified and met.
The International Classification of Diseases is used for a variety of clinical data management applications in today's health care systems. The replacement of ICD-9-CM with the ICD-10-CM and ICD-10-PCS represents significant opportunities for improved data capture and information storage. High quality data in electronic environments requires leading organizations through the transition process. In addition the changes required presents many opportunities for improvement in workflow and more effective data integrity management. HIM professionals are uniquely qualified to lead the process and this model provides guidance and support for the process.
Traditional practices within the paper record support a single error line through the original documentation. However, these practices will not necessarily transfer to a transcribed report, and new practices should be evaluated against organizational policy. As organizations move towards the integration of transcribed reports to the EHR as well as new applications such as electronic signatures, core HIM principles should be adapted to incorporate these new technologies. This toolkit is designed to provide guidance to HIM professionals when addressing amendment, correction, and deletions within a transcribed report.
The location of paper records may no longer be within the walls of the health information management (HIM) department, but rather at an off-site warehouse as the organization transitions to an electronic record. However, the management of these records continues to be important in an organization’s day-to-day operations. As such, these legacy records are often maintained to meet statute of limitation requirements of individual states or organizations. Understanding how to file, retrieve and maintain these paper records continues to be a core function of many HIM Departments. This toolkit is intended to provide guidance regarding terminal digit filing of paper records.
The readiness assessment and prioritization worksheet is a tool that enables organizations to initiate steps necessary to gather and organize information. Through this exercise of identifying and capturing information about what systems and processes need to be addressed through the ICD-10-CM/PCS transition, management will gain information on what must be addressed and where to apply resources in preparation for the change.
This tool will enable you to develop quantitative results through objective and subjective analysis. These results are formulated through a concentrated review of the strategic areas of your organization, assignment of weighted values, and the identification of the components/departments within your organization that must be transitioned to ICD-10-CM/PCS.
Please download the tool and use as you prepare for ICD-10-CM/PCS implementation. We are looking for volunteers to participate in a pilot with this tool to obtain feedback and hear best practices, recommendations for modifications, lessons learned, etc. We encourage you to reach out to Allison Viola, AHIMA’s director of federal relations, at Allison.viola@ahima.org or (202) 659-9440, ext. 13. Results of this pilot may be incorporated into the 2010 ICD-10 Summit.
Traditional practices within the paper record support a single-line strike-through of the original documentation for correcting erroneous information. These practices do not transfer to an electronic environment and media. HIM professionals will need to be proactive in developing and implementing new practices for their organization that is supported via organizational policy and procedures and specific to individual system limitations. This toolkit is designed to provide guidance to HIM professionals when addressing amendment, correction, and deletion functionality in an EHR.
Due to the success of the Recovery Audit Contractor (RAC) demonstration program conducted by the Department of Health and Human Services (DHHS), section 302 of the Tax Relief and Health Care Act of 2006 makes the program permanent and requires the Secretary to expand the program to all 50 states by no later than 2010. This tool kit provides guidance to health information management (HIM) professionals on how to prepare for and ensure compliance with the permanent Recovery Audit Contractor (RAC) program, including identifying an internal support team, developing policies and procedures, establishing an educational program, and following through with the responses to the RAC.
This toolkit is designed to support and guide organizations, HIM professionals, and information technology (IT) professionals in the examination of the issues and circumstances wherein the healthcare industry needs to define, support, and execute best practices in dealing with copy technology in the EHR environment. This toolkit is intended to assist these individuals in developing their own policies and procedures surrounding this functionality.
AHIMA has developed a Web-based tool kit as a resource to assist individuals and organizations interested in participating in health information exchange initiatives.
HIPAA Privacy and Security Tools
More than 130 articles on HIPAA Privacy and Security are available by clicking here.
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