For years we have heard that EHRs improve the quality of clinical documentation in the medical record. While this is absolutely true in terms of legibility, it may not be so true otherwise.
When Carolyn Taggett, RHIT, director of health information services at Northern Maine Medical Center in Fort Kent, found that it sometimes took weeks for coders to receive answers to their physician queries, she decided there had to be a better way.
Throughout 2011 we are including special content in honor of MRB's 25th year. This month we reached out to some long-time readers who have been on board since MRB's early years, including some who have read every single issue! Read on to find out what they had to say.
There are some Joint Commission EPs with which almost all hospital HIM departments struggle. Surveyors continue to focus on them, so chances are you should too.
Even with today's tight budgets, there are still ways you can brighten the faces of your staff members. We asked the MRB advisory board members for their best ideas and tried-and-true tactics. Here's what they had to say.
Editor's note: As part of our yearlong celebration of MRB's 25th year, we wanted to take a look back at article excerpts from years past. In some ways, things haven't changed much-getting physicians to complete documentation in a timely manner is still a challenge-but in others, it is clear that HIM has come a long way.
If you are gearing up for a computerized provider order entry (CPOE) implementation, there are some tips and tricks that will help you stay on top of the transition.
Hardware, software, people, policy, and process must work together to achieve your organization's EHR goals. One of the earliest matters that policy must address surrounds organizational readiness for an EHR. In fact, having a policy of regular readiness assessment is an important step toward success. Even if a certain project with a certain group goes smoothly, that doesn't guarantee success for another project. You may think a policy that focuses attention on planning is not necessary, but implementing an EHR is a spiral of change, with each cycle repeating itself in many ways, often with new twists and turns.
Somewhere between the third urgent item on your to-do list, getting your budgets prepared, and responding to the latest auditor's requests lies the omnipresent responsibility of nurturing the validity of the medical record. HIM professionals have traditionally been the legal custodians of the record. (After all, who else is daring enough to testify in court on the accuracy of the EHR?) Have we also by default become the custodians of data integrity?
I promised in a previous “Standards of the month”column that I would address Joint Commission standard MM.04.01.01 (orders for medication are clear and accurate), as this standard made it onto the 2010 top 10 list of standards with which hospitals were noncompliant. In fact, 30% of hospitals failed to comply with it.
