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By Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner for ICD10 Monitor Questions abound when reporting critical care services. Reporting Adult Critical care can be complicated. It is not only the coding but the rules and that go along with critical care. Many questions come up when reporting…
By John Lauerman and Jeran Wittenstein, with assistance by Joshua Fineman and Saritha Rai for Bloomberg Technology Many doctors still can’t use a transcription service made by Nuance Communications Inc. three weeks after the company was hit by a powerful, debilitating computer attack. Hospital systems including Beth Israel Deaconess in Boston and the University of Pittsburgh Medical Center…
By Lee DeOrio for For The Record In the face of a crisis, it’s often a good idea to take a step back and learn from the moment. Perhaps that’s not feasible until after the fact—it certainly isn’t in this case—but to place odds on it never happening again is foolish. On June 27, Nuance…
By Kay Merriweather, RHIA, CCS, CCS-P, COC, CHDA, CDIP; Leslie Slater, RHIA, CCDS, CIC, CRC; and Michele Bohley, RHIA, CCS for AHIMA “If it’s not documented, it wasn’t done.” This is one of the first axioms health information management (HIM) professionals learn. HIM professionals have witnessed the evolution of quality documentation, with patient education becoming…
By Susan Chapman for For The Record Findings from The Joint Commission show many surveyed hospitals house incomplete medical records. When so many aspects of health care revolve around quality documentation, it would be good to know that providers are accomplished medical record custodians. Depending on your perspective, the news on that front isn’t half…