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Ethical Standards for Clinical Documentation …
- https://www.ahima.org/media/r2gmhlop/ethical-standards-for-clinical-documentation-integrity-cdi-professionals-2020.pdf?oid=301868
- information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g. present …
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 …
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 records; the …
AHIMA's Long-Term Care Health Information Practice …
- https://library.ahima.org/Pages/Long%20Term%20Care%20Guidelines%20TOC/Legal%20Documentation%20Standards
- Legal Documentation Standards. This section will review the legal documentation standards for entries in and maintaining the medical record. In today’s healthcare …
Integrity of the Healthcare Record: Best Practices for …
- https://library.ahima.org/doc?oid=300257
- There are a number of existing rules and regulations on documentation principles and guidelines that primarily address documentation authorship principles, auditing, and …
Documentation and Data Improvement Fundamentals
- https://library.ahima.org/doc?oid=60174
- The clinical documentation in a patient's record forms the basis for current and future care of that patient by the healthcare provider. The documentation in the record will be relied …
AHIMA's Long-Term Care Health Information Practice …
- https://bok.ahima.org/Pages/Long%20Term%20Care%20Guidelines%20TOC/Legal%20Documentation%20Standards/Documentation%20Standards
- AHIMA's Long-Term Care Health Information Practice and Documentation Guidelines Legal Documentation Standards that Apply to Medical Records Defining Who May …
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, …
Quality Documentation within Physician Practices
- https://campus.ahima.org/audio/fastfacts/FRB0803.pdf
- “Medical record documentation is required to record pertinent facts, findings and observations about an individual’s health history including past and present illnesses, …
Best Practices in Medical Record Documentation and …
- https://library.ahima.org/doc?oid=105812
- Best Practices in Medical Record Documentation and Completion Best Practices in Medical Record Documentation and Completion This practice brief has been retired. It …
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