Regardless of the safeguards in place in any electronic document management system (EDMS), sometimes a document ends up in the wrong patient’s record. It was a reality in the paper world, and it is a reality in the scanned record world. Obviously, it was easier to rectify in the paper environment. So how does one address this issue with a hybrid electronic record?
When it comes to release of information (ROI), it may seem that exceptions are the rule. But you must know when you can and cannot release information to protect the privacy of your facility’s patients.
Those of us who work in clinical settings are familiar with situations involving medical ethics when it comes to patient care. End-of-life decisions, resource utilization vs. quality of outcomes, genetic testing, pro-life issues, and other hot topics create endless ethical and moral discussions. And don’t forget to mix in a little government healthcare policy and discussion on rationing of healthcare and on whether healthcare is a right or a privilege.
EHR implementation is a “big, hairy animal,” according to Meg McElroy,RHIA, MBA, HIM and medical staff services director at Children’s Hospital of Milwaukee. McElroy has been working toward having a fully electronic record for years. “It’s so expensive, and how do you just get it done?” she says.
The annual MRB salary survey for HIM directors and managers has come to a close and the results are in. Read on to find out what more than 1,000 of your peers had to say regarding their salaries, the various factors that affect compensation, and the effects of the down economy.
For years the demand for coders has exceeded supply, and for many possible reasons. This may be because coders do not think that salaries are commensurate with the knowledge, expectations, and stress. And coders often move on to other positions and do not make a career of coding.
Motivating staff to produce more when recognition of superior performance is limited or nonexistent is difficult. Remember that incentives need not be financial; they can be monetary or non-monetary, individual- or team-based. Organizations may offer them regularly or sporadically based on variable or consistent criteria.
The Affordable Health Care for America Act, passed in late March, may leave many HIM directors scratching their heads. After all, sweeping reform must mean change is coming, but what will it look like?
Despite the numerous jokes on the subject, physician illegibility is no laughing matter, and Kaweah Delta Medical Center knows it. That’s why, after The Joint Commission found problems with the facility’s physician legibility, Kaweah Delta developed a plan to address the problem.
Although The Joint Commission has not focused on the ongoing record review (ORR) process during surveys and hospitals have not received recommendations for improvement in this area, ORR is still vital to the success of any survey. ORR can also be useful for clarifications when a hospital feels a recommendation isn’t substantiated.
