Clinical Documentation Integrity And Its Impact On Information Governance

The American Health Information Management Association’s (AHIMA) 86th Convention and Exhibit was held September 27 – October 3 in the San Diego Convention Center, and Health IT Outcomes editor John Oncea had the opportunity to speak with a wide range of attendees.

Oncea was able to speak with AHIMA members and presenters about everything from the effective management of health data, to the need for medical records to deliver quality healthcare to the public, to electronic documentation and health record management. In addition, several of healthcare’s leading vendors shared how technology is enabling HIM professionals better manage the ICD-10 transition, save health systems millions of dollars, achieve HIMSS Level 7, and achieve favorable electronic health record (EHR) implementations.

In the following video, Bonnie Cassidy, senior director of HIM innovation at Nuance Communications and recipient of the 2014 AHIMA Distinguished Member Triumph Award, discusses the runaway train of clinical documentation and how, when records are wrong, clinicians miss out on the whole picture of the patient, leading to imperfect diagnosis.