Clinical Data Abstraction: A Research Study.

This is the second part in a two-part research study on clinical data abstraction. Clinical data abstraction is the process of capturing key administrative and clinical data elements from a medical record. Very little is known about how the abstraction function is organized and managed today.

Electronic Health Record (EHR) Abstraction.

The purpose of electronic health record (EHR) abstraction includes collection of data related to administrative coding functions, quality improvement, clinical registry functions and clinical research. This article examines the different abstraction methods, such as manual abstraction, simple query, and natural language processing (NLP). It also discusses the advantages and disadvantages of each of those methods.

Health Information Management Leaders and the Practice of Leadership through the Lens of Bowen Theory.

Even though leadership is one of the most examined topics in the organizational literature, its application in the field of health information management (HIM) has not been studied extensively. This descriptive, mixed-methodology study examined HIM leadership through the lens of Bowen theory. The researchers conducted surveys of HIM directors and managers, administrators and colleagues of HIM leaders, and HIM staff using focus groups, observations of meetings, and face-to-face interviews.

Physicians' Outlook on ICD-10-CM/PCS and Its Effect on Their Practice.

Background: The United States is one of the last countries to change from ICD-9-CM to ICD-10-CM/PCS. The compliance date for implementation of ICD-10-CM/PCS is expected to fall on October 1, 2015.

Objectives: Evaluate physicians' perceptions on the change from ICD-9-CM to ICD-10-CM/PCS and its effect on their practice, determine how HIM professionals can assist in this transition, and assess what resources are needed to aid in the transition.