· Obtain copies of the complete hospital record, especially the hospital discharge summary, operative report (when relevant), and inter-facility transfer report. These records can also be omitted during the transfer/admission process, though in many cases a unit clerk would help assist the CDI specialist with obtaining both physician progress notes and the complete hospital record.
· Work with acute care hospitals to clarify the date of the preceding hospital admission.
Also, in this issue
How an AHIMA Credential is Born
When you see a list of letters after a health information management (HIM) professional’s last name, it’s sometimes too easy to take for granted all the long, hard hours that went into earning and creating those acronyms. In the article “How an AHIMA Credential is Born,” Mary Butler discusses a story that is often overlooked: the lifecycle of bringing a certification into the marketplace.
According to Terrence Wright, AHIMA’s director of certification, this story demonstrates the rigorous scientific approach to developing the standards for the certification, ultimately resulting in the highly trained and effective professionals. AHIMA’s certification process is considered the “gold standard” based on several factors—one of which is the fact that AHIMA credentials are created using a scientific process.
Read these articles and more in the June issue of the Journal of AHIMA or online at journal.ahima.org.
About AHIMA
The American Health Information Management Association (AHIMA) represents more than 103,000 health information professionals in the United States and around the world. AHIMA is committed to promoting and advocating for best practices in health information and to actively contributing to the development and advancement of health information professionals worldwide. AHIMA’s mission is to empower people to impact health. www.ahima.org
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