Information Governance & Standards

 

Latest Discussion Posts

  • ​​Does your organization enable providers to revert to draft status signed notes, then re-sign with the updates/corrections?  Thanks. ------------------------------ Leah Beck, RHIA Supervisor, HIM ------------------------------

  • ​Here are a couple good resources on the subject. AHIMA. "Update: Maintaining a Legally Sound Health Record-Paper and Electronic."   Journal of AHIMA   76, no.10 (November-December 2005): 64A-L.       Website: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_028509.hcsp?dDocName=bok1_028509 ...

  • ​Is there a specific standard (CMS, Joint Commission) that require electronic entries in the medical record to show staff credentials? (RN, RT, LPN, CNA)? ------------------------------ Kay Butcher Director of Health Information Mgt. SJMH ------------------------------

  • ​No, I believe that is not a best practice. The overseeing provider may have some additions and even the resident may make edits or additions prior to finalizing. Check bylaws and regs on this as well to ensure you can code from a 1st year resident, many ...

  • We are new teaching hospital in our area ...1st class of residents... Can our inpatient coders or should our inpatient coders code from an un cosigned resident note. It will eventually be signed however like many facilities our providers are often delayed ...

Announcements

  • Information Governance Strategic Forum: Building Your Value Proposition

    Join speakers Lynne Thomas Gordon, AHIMA CEO;  Brian Smith, Sr. VP and COO Mount Sinai Doctors Faculty Practice; and Joe Ponder, VP Information Governance LifePoint Health as we explore building a value proposition and return on investment for information governance.  Learn from the experts who have implemented a formalized program and have demonstrated success stories.  May 16, AHIMA Chicago Office.

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