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Ethical Standards for Clinical Documentation …

    https://bok.ahima.org/doc?oid=301868
    The Ethical Standards for Clinical Documentation Improvement (CDI) Professionals are based on the American Health Information Management Association’s (AHIMA’s) Code of …

Documentation and Data Improvement Fundamentals

    https://library.ahima.org/doc?oid=60174
    Documentation and Data Improvement Fundamentals. Ruthann Russo, JD, MPH, RHIT . Introduction. The absence of complete documentation in patient medical records can …

Fundamentals of the Legal Health Record and …

    https://library.ahima.org/doc?oid=104008
    Designated Record Set. Legal Health Record. Definition. A group of records maintained by or for a covered entity that is the medical and billing records about individuals; …

Clinical Documentation Integrity Education & Training

    https://www.ahima.org/education-events/education-by-topic/
    AHIMA is committed to advancing CDI by providing education and training, certification (CDIP® credential), and other valuable resources to CDI …

Integrity of the Healthcare Record: Best Practices for …

    https://library.ahima.org/doc?oid=300257
    AHIMA. “Legal Health Record Leadership Model.” AHIMA e-HIM Work Group. “Guidelines for EHR Documentation to Prevent Fraud.” Journal of AHIMA 78, no. 1 (January 2007): …

AHIMA's Long-Term Care Health Information Practice …

    https://bok.ahima.org/Pages/Long%20Term%20Care%20Guidelines%20TOC/Legal%20Documentation%20Standards/Documentation%20Standards
    When fax records are maintained in the medical record the assurance must be made that the record will maintain its integrity over time. For example, if thermal paper is used for …

Ethical Standards for Clinical Documentation …

    https://www.ahima.org/media/r2gmhlop/ethical-standards-for-clinical-documentation-integrity-cdi-professionals-2020.pdf?oid=301868
    2.2. Comply with AHIMA's standards governing data reporting practices, including health record documentation and clinician query standards. 3. Query the provider (physician …

AHIMA's Long-Term Care Health Information Practice …

    https://bok.ahima.org/Pages/Long%20Term%20Care%20Guidelines%20TOC/Legal%20Documentation%20Standards/Legal%20Guidelines
    At times it will be necessary to make an entry that is late (out of sequence) or provide additional documentation to supplement entries previously written. Making a Late Entry. …

Best Practices in Medical Record Documentation and …

    https://library.ahima.org/doc?oid=105812
    Best Practices in Medical Record Documentation and Completion. This practice brief has been retired. It is made available for historical purposes only. You are trying to access a …

Legal Process and Electronic Health Records - AHIMA

    https://library.ahima.org/doc?oid=59559
    The custodian of an electronic health record (EHR) has the same concerns as the custodian of a paper health record when the record becomes involved in the legal process. Most …



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