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You are here > Home > Reading Lists > Information Systems, Medical Records  & Technology Books > Documentation for Acute Care

Documentation for Acute Care, Revised Edition
Jean S. Clark, RHIA; American Health Information Management Association

Softcover: 400 pages + bonus CD-ROMs
ISBN 1584261129
AHIMA
November 2004
Price: $84.95

 

This all-new publication replaces AHIMA’s classic Documentation Requirements for the Acute Care Patient Record

The book makes a handy reference for practitioners, consultants, transcriptionists, and other information systems specialists. The book and CD-ROMS bring you new and established guidance so you know how to successfully develop forms and meet standards and documentation requirements. 

Whether you need to assess an existing health record, create a new record, or devise an EHR, you can use the forms and guidelines published here as models. 

A wide array of forms and sample EHR screens are included so that users can boost their practical knowledge. This book and CD-ROM set provides information and tools for:

  • Health record law and HIPAA regulations
  • Electronic signatures
  • Nursing documentation
  • Late entries, addendums, clarifications, and physician queries
  • Documentation for speciality care
  • Includes chapter exercises, reviews, and detailed appendices that feature Joint Commission standards and more.
  • A free instructor’s manual is available online through the AOE CoP. 
  • The accompanying CD-ROMs also provide a complete sample record in paper format, a functional EHR demonstration, and information on EHR planning and implementation.

View a sample form or the table of contents. Recommended by AHIMA, this book covers:

  • Definition and Purposes of the Acute Care Record
  • Standards, Laws, and Regulations
  • Form and Format
  • Types of Acute Care Records
  • From Paper-Based Data Capture to Electronic Data Capture
  • Confidentiality and Security
  • Appendices
  • Glossary
  • Additional Resources

Jean S. Clark, RHIA, has worked in the HIM profession for over 25 years, holding management positions throughout her career. She has taught numerous seminars and authored a definitive guide on the Joint Commission on Accreditation of Healthcare Organizations’ record review standards. She served as AHIMA’s president in 1995 and, in 2000, received the AHIMA Distinguished Member Award. She is also president-elect of the International Federation of Health Records Organizations (IFHRO).

The American Health Information Management Association (AHIMA) is the community of professionals engaged in health information management, providing support to members and strengthening the industry and profession. A world in which the public values the contribution of health information management professionals and the American Health Information Management Association, in the advancement of health through quality information: 1) Provides career, professional development and practice resources; Sets standards for education and certification; and, Advocates public policy that advances HIM practice. AHIMA fosters the professional development of coding professionals through advocacy, education, certification, and lifelong learning opportunities.

Please remember: The government no longer allows a grace period for annual code sets. The new HIPAA Transaction and Code Set Rule requires providers to use national medical code sets that are valid at the time that a service is provided. ICD-9-CM code revisions become effective October 1st each year while CPT and HCPCS code revisions become effective January 1st. In order for you to meet this requirement, you must have the revised CPT, HCPCS, and ICD-9-CM codes in your possession before the implementation dates. The best way to do this is to order your code books early. Review current coding resources.

You may also be interested: Up-to-date Coding Resources

(information from the publisher)

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