Health record completion guidelines. American Health Information Management Association.
It is a pleasure to introduce this important project report to the American Health Information Management Association (AHIMA) membership. Analyzing records for omissions, notifying physicians of needed information, counting delinquent records, and pursuing late documentation are some of the biggest chores in today's health information management departments. And they are chores that take time away from other priorities--managing, analyzing, and presenting health data, planning and implementing computerization, assessing and meeting customer needs. The heart of this statement is simple: it points out that there are other options to the traditional, detailed, record-by-record analysis. And those options may give us the results we need--timely and complete health records--while freeing up valuable staff time for other priorities. Take a serious look at the statement. If you are eager to make a change in your department's practices in records analysis and completion, it will back you up. If you are comparing the value of your department's records completion work to its benefit, this statement will give you ideas for change. And if you don't think you'd ever challenge tradition, this statement will give you food for thought. An added value to this statement is the fact that the ideas in it, and the very statement itself, are the product of our own profession. We are fortunate that leading-edge practitioners gave their expertise to the entire profession. The members of the strategy group for this project are listed above, we thank them for their wisdom.
DeVitt
M P
MP
Haenke
B M
BM
Picukaric
J M
JM
Kerwin
J M
JM
Hettel
S
S
Cameron
M
M
Testa
F A
FA
Fainter
J
J
Feste
L
L
D003142:Communication; D004282:Documentation / Q000592:standards; D004496:Education, Continuing; D005568:Forms and Records Control; D007258:Informed Consent; D015274:Interdepartmental Relations; D008485:Medical Audit; D008499:Medical Records / Q000592:standards*; D008500:Medical Records Department, Hospital / Q000592:standards* / Q000639:trends; D009936:Organizational Innovation; D016134:Organizational Policy; D011785:Quality Assurance, Health Care / Q000592:standards*; D012952:Societies; D014481:United States