Aug 20, 2019
HIT 125 - Essentials of Health Records Credits: 2
Lecture Hours: 1
Lab Hours: 2
Practicum Hours: 0
Work Experience: 0
Course Type: Voc/Tech
This course familiarizes students with the origin, uses, content and format of health records, including both paper and electronic health records. It covers required standards for health records, organization of records and analysis of health record data. The fundamental components, terminology and functions associated with electronic health record (EHR) systems in the health care provider practice. This course also familiarizes students with technologies used in the field of medical transcription.
- Characterize the patient record.
- Define a health record.
- Differentiate among various types of patient records formats.
- Explain the purpose of patient record and provider documentation completion responsibilities.
- Explain the flow of post discharge processing of health information.
- List and explain the major functions of a health information management department.
- Explain the principles and process flow of an incomplete record system.
- Compare paper-based verses electronic records processing.
- Explain mehods for correcting errors in documentation.
- Discuss the importance of authentication of records.
- Differentiate between licensure, accreditation, regulations and list accrediting and licensure organizations/government agencies.
- Examine the content of the patient record and health record data.
- Explain general documentation requirements of health records and their compliance with accreditation standards and federal and state laws and regulations.
- Describe the contents of inpatient, outpatient and physician office records.
- Differentiate among administrative and clinical data collected on patients.
- Describe the flow of clinical data through an acute care facility.
- List and understand the required reports and data elements in clinical reports and health record.
- Given a data element, identify the appropriate orginal source of data.
- List elements of Uniform Hospital Discharge Data Set (UHDDS).
- Distinguish between data and information.
- Define primary and secondary data.
- Distinguish between characters, fields, reports, files.
- Explain indexes, registries, research studies and health data collection.
- Define key terms related to indexes, registries and health data collection.
- Identify, describe and understand purpose of registries maintained by health care facilities and state and federal agencies.
- Explain the purpose of a master patient index.
- Discuss the importance of maintaining accurate and permanent retention of MPI.
- Describe the differences and advantages/disadvantages between manual and computerized MPI.
- Discuss clinical research and trails including Medicare qualifying trials, IRB and research informed consent.
- Discuss the characteristics of health data collection and ensuring data quality.
- List and explain key data categories.
- Define data sets used in health care and identify their applications and purposes.
- Examine the role of medical transcriptionists.
- Define medical transcription.
- Describe duties performed by transcriptionists.
- Identify the types of documents produced.
- Explain the uses of transcribed data.
- List basic competencies of medical transcriptionists.
- Name the reference materials used by transcriptionists.
- Identify work settings for transcriptionists, including home based offices.
- Differentiate between clinical and hospital transcription.
- Discuss how accurate transcription contributes to safer and higher quality care.
- Describe health information technologies used for medical transcription
- Describe the flow of data from the point of care to transcription to health care information systems.
- Identify equipment used for transcription.
- Describe the role of the Internet in transcription.
- Identify privacy and security controls for transferring data via the Internet.
- Understand compliance with style and formatting requirements.
- Describe speech recognition technology.
- Describe the job outlook for medical transcriptionists.
- Summarize education and training requirements for a transcriptionist.
- Discuss certification opportunities.
- Explain the increasing demand for transcription services.
- Describe compensation methods for transcriptionists.
- Characterize the role of the EHR in facilitating complete documentation, efficient workflow and timely communications among clinicians, staff and patients.
- Understand the applications used for practice management and EHR including the purpose, advantages/disadvantages and an overview of flow of patient information.
- Explain the transformation of data into information and the professions who play a key role in the process, what tools and applications are used to collect data and laws and standards that govern health information.
- Identify data elements that make up administrative data and learn the steps necessary to make an appointment and register a paient, collect administrative/demographic data and capture insurance information.
- Use an EHR for data collection and maintenance of past medical, surgical family and social histories and understand importance of data accuracy and proper handling of inconsistent, unclear or incorrect data.
- Examine the care providers collection and use of healthcare data including documentation of patient’s history of present illness, review of system, physical exam and meaningful use requirements in relation to maintaining a problem list, e-prescribing and computerized order entry.
- Define the claims management process including use of superbill, ICD-9-CM, CPT, HCPCS coding and understand the basics and importance of billing and coding procedures and policies and standards to ensure compliance with regulations and agency requirements.
- Describe the regulations such as HIPAA and HITECH including privacy and security standards and methods to maintain security safeguard data integrityy and audit compliance with access and release of information. Using EHR understand Meaningful Use of electronic data for continuity of care and accounting for data disclosures.
- Examine the management of information and communication utilizing an EHR as a communication tool, imprinting documents in nonelectronic format, use of templates for standardized data collection, importance of screen customization for flexibility to care providers to improve satisfaction of using electronic tools and use of alert system including task list and system flags to improve patient outcomes.
- Use the EHR database to write custom and system generated reports and explore database in its use in decision support for clinical and administrative reasons and data collection resulting in information for credentialing process.
- Explain the future of electronic environment in healthcare including health informatics, telemedicine, telehealth and patient medical homes and devices that make collection and sharing of health information more timely and efficient but remains secure.
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