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Documentation and Data Improvement Fundamentals

    https://library.ahima.org/doc?oid=60174
    The two most important aspects of patient medical record documentation are as follows: The attending physician's documentation is key throughout the patient's stay. In each …

Fundamentals of the Legal Health Record and …

    https://library.ahima.org/doc?oid=104008
    The HIPAA privacy rule defines the designated record set as a group of records maintained by or for a covered entity that may include patient medical and billing …

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) …

Integrity of the Healthcare Record: Best Practices for …

    https://library.ahima.org/doc?oid=300257
    Documentation guidelines: The education program needs to clarify and reinforce that the HIM documentation requirements and documentation guidelines accepted and …

Ethical Standards for Clinical Documentation …

    https://www.ahima.org/media/r2gmhlop/ethical-standards-for-clinical-documentation-integrity-cdi-professionals-2020.pdf?oid=301868
    The Ethical Standards for Clinical Documentation Integrity (CDI) Professionals are based on the American Health Information Management Association’s (AHIMA’s) Code of …

Clinical Documentation Integrity Education & Training

    https://www.ahima.org/education-events/education-by-topic/
    Leadership. Overview. Clinical documentation is at the core of every patient encounter. In order to be meaningful, the documentation must be clear, consistent, …

AHIMA's Long-Term Care Health Information Practice …

    https://bok.ahima.org/Pages/Long%20Term%20Care%20Guidelines%20TOC/Legal%20Documentation%20Standards/Documentation%20Standards
    The use of adhesive labels in the medical record is an accepted practice in the health care industry including long term care. Labels or label paper (adhesive-backed paper) are …

Legal Process and Electronic Health Records - AHIMA

    https://library.ahima.org/doc?oid=59559
    AHIMA defines the legal health record as "generated at or for a healthcare organization as its business record and is the record that would be released upon request. It does not …

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 …

AHIMA Home

    https://www.ahima.org/
    AHIMA, AMIA, and EHRA announced today the release of a final report that examines key issues related to operationalizing the definitions of “electronic health information” (EHI) …



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