Documenting System-Created Issues in the Medical Record
Jun28

Documenting System-Created Issues in the Medical Record

Technology does not always function as planned, even now in the era of electronic health records. Proper documentation is essential for data integrity and the integrity of the medical record. This documentation enables staff to identify when a system issue has occurred and to determine the impact on the medical record.

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What Does It Mean When ESI is “Lost”?
Jun26

What Does It Mean When ESI is “Lost”?

“Remedial measures,” also known as “sanctions,” can be imposed under Federal Rule of Civil Procedure 37(e) when electronically stored information is lost. The word “lost” has a specialized meaning in this context

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2020 Proposed Rule Changes For ICD-10-CM Codes
May28

2020 Proposed Rule Changes For ICD-10-CM Codes

The Proposed Inpatient Prospective Payment System (IPPS) Rule was published on April 23, 2019. This month’s Code Cracker takes a look at some of the changes, including the 273 new codes, 21 deleted and 30 code title revisions revealed in the FY 2020 Proposed Rule Tables.

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When Healthcare Providers and Privacy Legislation Collide
May15

When Healthcare Providers and Privacy Legislation Collide

In response to the increasing issue of data breaches, a number of proposals for legislation related to breaches and personal privacy have been made at both the federal and state levels.

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Skewed Public Perception of the CDI Role and Impact in Healthcare
May08

Skewed Public Perception of the CDI Role and Impact in Healthcare

It seems lately that every time you turn on the television there is a new medical drama starting. Unfortunately, the depiction of healthcare and the patient encounter is offered in a very skewed view depending on the story line and intended impact.

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IR-DRGs and CDI in the UAE: AHIMA World Congress
Apr24

IR-DRGs and CDI in the UAE: AHIMA World Congress

Clinical documentation improvement holds much promise for healthcare providers beyond the United States, including exciting opportunities for Al Ain Hospital, AWC’s newest organizational member, and other providers in the UAE related to International Refined Diagnosis-Related Groups.

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