The Business of Managing Medical Records

Lesson 3, Step 6

AHIMA (American Health Info Management Association)

They provide a list of documentation guidelines that heath professionals follow

What are examples of good recording practices

Legible and Understandable

Legibility

If the document has an illegible section, but it is legible somewhere else, the provider does not need to correct it

Understandable

The provider must use accepted abbreviations, and patient charts must be consistent with the practice’s standards

Timely

If a record is not signed within 30 days, it becomes deliquent

Error Free

Providers must try to make as little documentation errors as possible

Reproducible

Must be able to be copied, the use of black ink in medical records is crucial

Amendment

Clarifying details added to a patient’s chart as part of an addendum

Addendum

The addition of information that was left out of the original record

How do you correct a medical record?

Cross out original entry with a single line

Audit Trail

The ability to track corrections and changes to a medical record electronically

Audits

Formal checks to the EMR (Electronic Medical Record) to ensure it’s working correctly