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Feb 08, 2025
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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 provides an overview of recordkeeping practices in the inpatient and outpatient healthcare settings. Emphasis is placed on hospital and medical staff organization, patient record content, procedures in filing, numbering and retention of patient records, quantitative analysis, release of patient information, forms control and design, indexes and registers, reimbursement, regulatory and accrediting agencies, and alternate health care delivery systems. Competencies
- Introduce health information management concepts common to allied health professionals
- 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 versus electronic records processing
- Explain methods for correcting errors in documentation
- Discuss the importance of authentication of records
- Examine characteristics of health care delivery and settings in the United States
- Describe acute care settings in health care
- Identify ambulatory and outpatient care settings
- Define behavioral health care facilities
- Compare home care and hospice
- Define the functions of managed care
- Compare the roles of local, state, and federal governments on health care
- Delineate career opportunities for health information management professionals
- Summarize education and training requirements for the field
- Discuss certification options
- Explain the increasing demand for health information management professionals
- Identify professional associations applicable to health information management professionals
- Define professional ethics
- Evaluate types of patient records, including documentation issues associated with each
- Explain general documentation requirements of health records
- 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 the required reports and data elements in clinical reports and health record
- Given a data element, identify the appropriate original 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
- Characterize the role of the electronic health record
- Outline applications used for practice management and EHR including the purpose, advantages/disadvantages and an overview of flow of patient information
- Identify data elements that make up administrative data and learn the steps necessary to make an appointment and register a patient, 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
- 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 technology in healthcare
- Explain indexes, registers, and health data collection
- Describe numbering and filing systems and record storage and circulation methods
- 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 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 legal aspects of health information management
- Discuss legal terminology and regulatory terms
- Describe patient confidentiality and HIPAA privacy and security provisions
- State the impact of legislation on the field of health information
- Differentiate between licensure, accreditation, regulations and list accrediting and licensure organizations/government agencies
- Provide an overview of coding and reimbursement issues
- Identify the classification systems and nomenclatures utilized for medical coding and reimbursement
- Define the claims management process coding
- Illustrate an understanding of billing and coding procedures to ensure compliance
- Identify third-party payers in healthcare
- Discuss healthcare reimbursement systems
Competencies Revised Date: AY2023
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