Strengthening Your Medical Records Program: How RHIA and RHIT Consultants Help Facilities Navigate CMS Compliance

Strengthening Your Medical Records Program: How RHIA and RHIT Consultants Help Facilities Navigate CMS Compliance

When a CMS survey results in a citation, it can quickly become a wake-up call. It might come as an even bigger surprise if you’re cited for not having a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) involved in your medical records program. This citation underscores a growing need for facilities of all sizes to ensure their health information management (HIM) practices meet federal expectations.

CMS requires all providers to maintain a comprehensive medical records program that protects the integrity, confidentiality, and accessibility of patient records. According to the CMS State Operations Manual, documentation must be complete, accurately timed and dated, and promptly authenticated.

But increasingly, surveyors are looking beyond surface-level compliance. They’re assessing who is responsible for medical records oversight. If there’s no credentialed HIM professional, such as a RHIA or RHIT, actively overseeing the process, the facility risks being flagged.

Here’s what CMS surveyors are looking for:

• Clear policies and procedures for medical records management
• Qualified personnel with appropriate HIM credentials
• Ongoing quality assurance and documentation audits
• Evidence that HIM oversight is not just “on paper,” but active and ongoing

At YES HIM Consulting, we specialize in helping organizations across the country – from large health systems to independent practices and ASCs – build compliant, efficient medical records programs. Whether your facility was just cited or you’re proactively strengthening your compliance efforts, our RHIA and RHIT experts are equipped to guide your team through the entire process.

The YES HIM Approach: Proactive, Practical, and Credentialed Support

When a client comes to us after a CMS citation or is preparing for an upcoming survey, we take a structured and personalized approach to ensure their medical records program meets CMS expectations and industry best practices.

Here’s how our RHIA/RHIT-led process works:

Step 1: Comprehensive Policy and Documentation Assessment

Our first step is to conduct an in-depth review of your current medical records policies and documentation practices. We evaluate:

• Record retention schedules
• Policies for documentation timeliness and completeness
• Authentication and signature practices
• Staff training procedures and role definitions
• Use of EMR systems and integration

We also assess how well your program aligns with CMS Conditions for Coverage (CfCs) and AHIMA best practices.

Step 2: Actionable Reporting for Leadership

After the assessment, we provide a clear, structured report that outlines:

• Areas of non-compliance
• Opportunities for improvement
• Recommended updates to existing policies
• Suggested workflows to strengthen documentation practices

Our reports are written for leadership and include guidance on how to implement recommendations efficiently.

Step 3: Ongoing Consultation and Partnership

Compliance isn’t a one-time event; it’s a continuous process. That’s why we offer ongoing support with your RHIA or RHIT consultant for just a few hours each month. This ensures:

• Your facility keeps pace with changing regulations.
• Staff have a resource for documentation and policy questions.
• Policies remain current and effective.
• Periodic internal audits are performed with expert oversight.

Our consultants become an extension of your team, not just a one-time fix.

Why Credentialed HIM Oversight Matters

Bringing in a RHIA or RHIT professional signals to CMS and your patients that your organization prioritizes accurate, compliant health information management. It also improves operational efficiency by reducing documentation errors, streamlining workflows, and minimizing the risk of denials or legal exposure.

CMS is raising the bar, and organizations of all sizes must evolve accordingly. At YES HIM Consulting, we understand that every facility is different. That’s why our solutions are tailored, not templated. We work closely with your internal team to deliver real results without unnecessary complexity. In short, our consultants provide more than compliance; they deliver peace of mind.

If CMS has cited your ASC or practice for gaps in your medical records program or you want to prevent future citations, don’t wait. A proactive approach with the right credentialed expert can make all the difference.

Reach out to YES HIM Consulting to schedule an assessment and take the first step toward compliance and confidence.