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Editor's e-Note
What would we do without control-C and control-V, the keyboard functions that go hand-in-hand like a HIPAA audit and a migraine? In the name of efficiency, we take advantage of these soul mates to make our lives easier. No shame in that.

However, when it comes to clinical documentation, an overreliance on copy and paste can lead to serious long-term damages. This month’s E-News Exclusive explains the dangers and offers suggestions on how to properly use everyone’s favorite shortcuts.

Lee DeOrio, editor
e-News Exclusive
Copy-Paste and the EHR:
Realizing the Benefits While Minimizing the Risk

By Linda McIntyre, RN

In the “olden days” before EHRs, physician notes were expected to flow in a narrative style to tell the “story” of the events leading up to and resulting in a patient’s illness or injury. These events were relayed in chronological sequence with relevant clinical commentary regarding diagnosis, prognosis, and treatment plan. Laboratory and other diagnostic results were appropriately included. These notes were typically dictated, transcribed, and then reviewed by the doctor prior to signature.

With the adoption of the EHR, the ability to create their own notes in real time has been a convenient feature for physicians. One function that is frequently used is copy-paste. This can be a great time-saver since it allows a physician to quickly incorporate lab results, vital signs, and related data into the note.

Full Story »
Industry Insight
Personal Connected Health Alliance, HIMSS, and Games
for Health Announce Strategic Partnership

The Personal Connected Health Alliance (PCHA) at HIMSS and the Games for Health Project announced a strategic partnership to deliver comprehensive resources and business development opportunities to the gaming community. HIMSS and PCHA are focusing on advancing personal health technologies in care delivery, including mobile and connected health, that empower and engage providers, patients, and consumers in health and wellness.

Games for Health represents the full spectrum of health technologies. This partnership will bring greater focus to cutting-edge games and gaming technologies covering the spectrum from wellness to disease management.

“Gaming technology is playing an increasing role in care delivery and the management of health and wellness,” says Richard Scarfo, vice president of PCHA and director of the mHealth Summit. “Our strategic partnership with Games for Health complements PCHA’s support of the full continuum of technology-driven health and wellness. Gaming technology is becoming an important addition to social media, wearables, and mobile health, as well as an adjunct to clinical care management.”

Read more »
In this e-Newsletter
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A Phish Story
Health care data thieves can snag their unsuspecting targets by taking them on a phishing expedition. Read more »

How to Outsmart ROI Challenges
By following some basic tenets, health care organizations can stress less about their release of information processes. Read more »

Upping the Ante on Meaningful Use Audits
The Office of Inspector General is approaching these reviews with a renewed fervor and an eye on security concerns. Read more »

Service Market Chaos
Certified EHRs and ICD-10’s arrival have made life more difficult for HIM service vendors. Read more »
Other News
Are Digital Health Technologies
Really Good for Our Health?

Countless digital health companies and mobile apps are available, but not many have concrete evidence to support their health claims, Fortune reports.

AHIMA’s Newest Toolkit
Focuses on Information Governance

A new toolkit from AHIMA shares best practices and resources for starting and implementing information governance within an organization.
AHIMA Conference Preview
Let the Good Times Roll at AHIMA
By Heather Hogstrom

AHIMA’s 87th Annual Convention and Exhibit will be held September 26-30 in New Orleans. “The Big Easy,” known for its cuisine, jazz music, and of course Mardi Gras, offers plenty for visitors to enjoy. To get a taste of the “Fat Tuesday” tradition, conference attendees can end Tuesday night with the Appreciation Celebration at Mardi Gras World. The Convention Center is in the Warehouse Arts District, which features museums such as the Ogden Museum of Southern Art and the Contemporary Arts Center, while the popular French Quarter has plenty of restaurants, music venues, and shopping to explore.

Read more »
Featured Jobs
The nation's top employers and recruiters of HIM talent advertise in For The Record magazine and post their job openings on Check out the most recent opportunities that have been submitted by employers across the country!

Remote Inpatient Coders—M*Modal
Coders/Coding Consultants—Amphion Medical, FT/PT, Home-based
MLS/Speech Understanding Editors—Amphion Medical, FT/PT, Home-based
Remote Coders & Auditors—Prospective Payment Specialists, FT/PT
Coders—Health Information Associates, Pawleys Island, SC
Health Information Management/HIM—UCHealth, Fort Collins & Aurora, CO
Ak the Expert
Have a coding or transcription question? Get an expert answer by sending an e-mail to

This Month’s Selection:
What would be the most appropriate code to report the following scenario? Patient comes with right brachial vein thrombophlebitis and forearm cellulitis due to self-injected heroin. He is a heroin dependence-continuous.

Would it be correct to report the thrombophlebitis and cellulitis and then add the E code for self-inflicted injury? Some coders are using the code for infection following injection (999.39). I disagree since this is not [considered] medical care.

Carmen L. Rivera
Remote Auditing Consultant

The correct codes for this scenario would be 451.83, phlebitis and thrombophlebitis, deep veins of upper extremities; 682.3, other cellulitis and abscess, upper arm and forearm; and 304.01, opioid type dependence, continuous. If I knew the organism causing the cellulitis, I would also code that.

I would not code a complication code; 999.39 is used when the patient has an infection following an infusion, injection, transfusion, or vaccination. I agree that this is not due to medical care.

I would not code an E code—either E959 or E920.5. If the coder was to follow Official Coding Guidelines, Section 1, c.19.g3, “A late effect E code should never be used with a related current nature of injury code.”

— Arlene Baril, MHA, RHIA, CHC, is senior director of facility coding and auditing for Altegra Health.
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Coming up in our November issue is our Technology & Software Showcase. Contact sales for more information. is the premier online resource to recruit HIM professionals. Post your open positions, view résumés and showcase your facility's offerings all at!
Tech & Tools
TouchCare Telemedicine App
Adds Provider-to-Provider Consults

TouchCare’s product update gives physicians and health care providers an easy way to do video consults with their peers or colleagues. Adding to the app’s ability to connect providers with their own patients, the new My Colleagues feature allows providers to invite other providers to join their private networks on TouchCare, schedule HIPAA-compliant video consults with each other, or make themselves available for on-demand consults. Providers can talk privately with another doctor or sit alongside their patient to present their case to a specialist. The update also includes improved e-mail and in-app appointment confirmation notifications. Additionally, a new My Clinics feature for patients allows them to easily access all information for a provider’s clinic, such as the phone number, directions, and a list of all physicians. Learn more »

App Helps Consumers Save
on Prescription Drugs

OneRx enables users to review drug pricing and benefits data; compare the costs of carrier-specific drug copays with additional, comprehensive money-saving options; research individual drug and pharmacy prices; and identify prescriptions that offer the best value while meeting their medical needs. The app takes into account hundreds of manufacturer coupons, pharmacy discounts, and other deals available to those with and without coverage; automates the process of amassing coupons; and provides automatic alerts when drug-specific insurer restrictions surface. OneRx is free, HIPAA compliant, and independently owned. Learn more »

Imprivata Launches Patient ID Platform
Imprivata PatientSecure is a positive patient identification solution that uses palm vein biometrics to create a one-to-one link between patients and their correct medical record in their provider’s EHR system. Palm vein scanning is nonintrusive, safe, and accurate. The solution directly integrates with leading health care information systems and helps improve patient safety and satisfaction, eliminate duplicate medical records and overlays, drive revenue cycle efficiency, and safeguard against identity theft and insurance fraud. Learn more »
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