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| HITT101 syllabus
|COURSE NUMBER: ||HITT101|
|COURSE TITLE:||Introduction to Health Information|
|SEMESTER CREDIT HOURS:||4|
|STUDENT ENGAGEMENT HOURS:||180|
The course covers a brief history of health care in the United States. The organizational structures of health care facilities, regulatory agencies, accreditation and licensure of health care agencies will be covered. The role of a health information technologist, and the function of a health information department will be studied. Emphasis will be on the content and structure of the health record, techniques employed to assure accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy and timeliness of the documentation of a medical record. Computerized patient records, secondary data sources, and clinical vocabularies are also introduced. Additionally, students gain experience in a virtual health information department within the virtual lab.
Completion of or current enrollment in BIOL136
This course is not available for web registration.
STUDENT LEARNING OUTCOMES:
Upon completion of this course, students will be able to:General
The HIM Profession
- Recognize the important milestones in the historical development of medicine and regulations in relation to the Health Record and the Health Information Management Department.
- Compare and contrast the different health care organizational structures in the health care field.
- Interpret the legislation that impacts and that regulates the health care delivery system in the U.S.
- Critique the current U.S. health care delivery system, its providers and health service organizations in relation to the Health Information Management (HIM) profession.
- Illustrate the difference between data and information in relation to health care and give examples of each.
Health Care System
- Interpret the purpose of American Health Information Management Association (AHIMA) and contrast membership categories within AHIMA.
- Explore the development, purpose, and structure of the Health Information Management profession and AHIMA.
- Research the possible employment opportunities of a Health Information Management Technician.
- Analyze the importance of AHIMA to your career.
- Illustrate an understanding of the ethics of health care professionals, especially the code of ethics published by AHIMA.
- Describe the future directions of the HIM profession.
Health Information Record (content, standards, etc.)
- Classify a hospital by type of ownership and organization.
- Classify the different role(s) of each hospital department as it relates to the functions of the hospital and the physician’s office.
- Interpret an organization chart depicting hospital departments.
- Prepare an organizational chart for a health care facility.
- Contrast the purposes of the following medical staff committees and their functions; infection control, medical records review, quality assessment, blood usage review, drug usage evaluation, disaster planning, utilization review, surgical case review, risk management, safety, autopsy review compliance.
- Interpret the purposes and content of by-laws in relation to the HIM department and the HIM professional.
- Determine the role and responsibilities of the governing body and administrative heads employed in health care organizations.
- Compare and distinguish between the different roles of regulatory agencies, accreditation organizations, certification, and licensure in the health care field.
- Analyze state and federal regulations and their relationship to accreditation standards for health care organizations and the health record.
- Differentiate the role of various providers and discipline throughout the continuum of healthcare and respond to their information needs.
Health Data Sets
- Analyze given cases and identify them as data or information.
- Analyze the benefit of color-coding in filing paper charts.
- Compare and contrast the structure uses of Health Information by the different uses according to purpose and use.
- Illustrate an understanding of the data collection tools (forms, screens, etc.) found in a health record.
- Illustrate a clear understanding of data definitions, vocabularies, terminologies and dictionaries in case studies.
- Identify ownership of the health record.
- Analyze given cases and the patients right to privacy and the requirements for maintaining the patient-identifiable health information.
- Develop a flow chart of the typical health record from its creation to permanent filing (manual and computerized data base).
- Sequence acute care facility inpatient reports in a logical filing order.
- Verify timeliness, completeness, accuracy, and appropriateness of data and data sources for patient care and registries.
- Maintain the accuracy and completeness of patient record as defined by organizational policy and external regulations and standards.
- Conduct a health record analysis to ensure that documentation in the health record supports the diagnosis and reflects the patient’s progress, clinical findings, and disease.
- Compare and contrast the documentation requirements of accreditation organizations with state and federal governmental agencies.
- Demonstrate knowledge of appropriate record content for medical, surgical, newborn, and obstetric record and the health care professionals responsible for completing the different sections.
- Discuss the importance of data integrity, data validation and data security as it relates to managing documentation and the health record.
- Examine the importance of confidentiality and security in relation to the health record.
- Recognize appropriate and inappropriate amendments made to patient records.
- Read and comprehend the documentation within medical record including interpretation of physician orders.
- Relate the role of the health information practitioner in providing data, analysis of data, and suggestions to improve documentation in the health care setting.
- Describe and contrast the responsibility for the health records in a health care facility by governing body, administration, attending physicians, other health care professionals, and the health information department.
- Describe the steps typically involved in processing health records.
- Given a group of medical records, analyze the record for quantitative and qualitative deficiencies.
- Determine which notification letter would be given to a physician depending on incomplete record status (incomplete, delinquent).
- Calculate deficiency and late chart completion rates.
- Conduct qualitative analysis to assure that documentation in the health record supports the diagnosis and reflects the progress, clinical findings, and discharge status of the patient.
- Ensure patient’s records documentation meets state and federal regulations.
- Control access to health information.
- Monitor documentation for completeness.
- Identify the concepts and evolution of the electronic health record.
- Identify and define terms associated with
Electronic Health Record (EHR).
- Describe the current state of EHR implementation and various initiatives to promoted adoption of EHR.
- Describe the technologies that help transition to the EHR and their impact on HIM functions.
- Discuss EHR challenges and the supporting role of HIM professionals.
- Analyze an EHR for deficiencies.
- Appraise the advantages of EHR over paper-based health records.
- Identify barriers to the development of the EHR and devise methods of overcoming these barriers.
- Interpret/identify a clear understanding of the computerized patient record and its benefits over the paper record.
- Describe the purpose of healthcare data sets and standards.
- Explain the importance of healthcare data sets and standards.
- Identify the common health information standardized data sets.
- Explain the need for electronic data interchange standards.
- Explain the healthcare data needs in an electronic environment.
- Discuss how data standards are developed.
- Identify well-known standards that support electronic health record.
- Identify health information standards development organizations.
- Recognize the impact of the
Health Insurance Portability and Accountability Act (HIPAA) on the development of health informatics standards.
- Explain the relationship of core data elements to healthcare informatics standards in electronic environments.
- Describe current federal initiatives to support EHR development and to create a nationwide Health Information Network.
- Analyze charts to ensure that the elements of the
Uniform Hospital Discharge Data Set (UHDDS) are present.
- Illustrate a clear understanding of healthcare data sets
(Outcome and Assessment Information Set (OASIS), Healthplan Employer Data
Information Sets (HEDIS), Data Elements for Emergency Department Systems
(DEEDS), UHDDS) by identifying the appropriate data set for given case studies.
Health Information Department
- Illustrate an understanding as to why there is new direction in clinical vocabularies.
- Relate the history, uses, and structure of International Classification of
Diseases, Ninth Revision (ICD-10-CM), International Classification of Diseases, Tenth Revision (ICD-10), International
Classification of Diseases, Oncology, Third Revision (ICD-0-3), the Healthcare
Common Procedure Coding System (HCPCS), Current Procedural Terminology (CPT),
Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT), Diagnostic and
Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) and nursing vocabularies and the reason each was developed.
- Identify the technology used in the coding process.
- Understand the history, elements, policies, and procedures for corporate compliance.
Secondary Records and Indexes
- Compare and contrast the functions and responsibilities of the different areas of a Health Information Management department.
- Analyze the responsibilities of the Health Information Management department in respect to: governing body, hospital administration, health informatics management, attending physician, and other health care professionals.
- Use appropriate technology, including hardware and software, to ensure data collection, storage, analysis and reporting of information.
- Apply techniques of the different methods by which data is gathered and maintained by the health information department to support patient related information systems needs and departmental operations and services.
- Given typical health information management activities, identify if the function is paper-based, computer-based, or both.
- Apply policies and procedures to ensure organizational compliance with regulations and standards.
- Apply policies and procedures to ensure the accuracy of health data.
- Analyze and apply the following computer applications giving advantages, and disadvantages of each: bar coding, deficiency system, chart tracking, master patient index, correspondence system, encoder, optimizer, and clinical data editor.
- Select the care data elements for inclusion in the
Message Passing Interface (MPI) in the different health care settings based on
American Medical Association (AMA) and AHIMA recommendations.
- Search for specific patients using find functions on the computer.
- Demonstrate an understanding of alphabetical filing rules by arranging lists of names in correct order.
- Justify choosing either centralized or decentralized filing system and cite advantages and disadvantages of each in a given situation.
- Analyze the following type of filing equipment: open, storage boxes, filing cabinets, elevator files, gliding files and choose the best option for a given situation.
- Compare the duties of the file room in relation to creation, storage, retrieval, and retention of the health record.
- Defend the importance of information security in a file room specific and health information department in general.
- Demonstrate an understanding of the unit, serial unit, and serial numbering system by defining and giving specific examples of number assignment.
- Justify choosing either straight number or terminal digit filing in a given situation.
- Sequence patient record numbers in terminal-digit and straight numeric filing order.
- Appraise the various numbering systems for a health care system and recommend the appropriate one for the settings.
- Demonstrate knowledge of manual and automated medical record tracking system.
- Appraise various filing controls and administrative concerns connected with managing and supervising tracking/chart control activities.
- Develop charts and graphs for specific topics.
- Analyze how the Statute of Limitation impacts record retention.
- Interpret influencing factors and legal requirements involved in determining retention of health records.
- Compare AHIMA and
American Hospital Association (AHA) resolution on retention of health records.
- Compare and contrast the following methods for retention; in-house filing,
remote on-site storage, remote off-site storage, microfilm, optical card, disc,
online computer storage, and purge/destroy and defend which would be the method
of choice in a given situation.
- Apply retention and destruction policies for health information.
- Determine the authority required, extent to which a record can be condensed, and advantages and disadvantages of condensing health records.
- Define microfilm and analyze the reasons for considering microfilming and reason why it may or may not be practical.
- Compare and contrast the different forms of microfilming (roll, jacket, microfiche, aperture cards, etc.) and in which situation each would be the system of choice. Describe the steps in preparing record for microfilming.
- Compare and contrast optical imaging as storage vs. computerized patient record format.
- Develop steps for implementing an optical imaging system.
- Classify the necessary components of an optical imaging system and the various cost factors involved in implementing an optical imaging system.
- Evaluate a hypothetical storage and retrieval system and determine
an alternative solution to solve identified problems.
- Apply information policies and procedures required by national health information initiatives on the healthcare delivery system.
- Apply current laws, accreditation, licensure and certification standards related to health information initiatives from the national, state, local and facility level.
- Discuss patient’s right and privacy in regards to his/her health record.
- Develop a job description for release of information based on HIPAA.
- Analyze requests for patient information by applying policies and procedures based on HIPAA.
- Illustrate an understanding of Health Information Systems (administrative,
admission-discharge-transfer (ADT), EHR, Personal Health Record, lab, radiology, pharmacy).
- Monitor and apply organization-wide health record documentation guidelines.
- Analyze data health record documentation.
- Identify anomalies in data.
- Distinguish between primary and secondary data and between patient identifiable and non-patient identifiable data.
- Define key terms related to registries.
- Compare manual and automated methods of data collection for indexes.
- Design appropriate methods for ensuring data security and the
confidentiality of secondary records.
- Develop methods to assess data quality issues in secondary records.
- Describe the difference and similarities between disease, operation, physician and patient index.
- Given hypothetical situations, identify which indexes (database) one would use to retrieve requested information.
- Create reports from a discharge abstracting system.
- Describe the purpose, format and location of the birth, death, and operation registers.
- Abstract data from health records for the generation of department indices, databases, and registries.
Collect, maintain, and report data for clinical indices/databases/registries to meet specific organization needs such as medical research and disease registries.
- Maintain the master patient index (i.e., enterprise systems, merge/unmerged medical record numbers, etc.).
- Eliminate duplicate documentation.
- Organize data into a usable format.
- Gather/compile data from multiple sources.
- Input and/or submit data to registries.
- Abstract data from 3M software located in the lab on given diseases and procedures and create reports using both tables and graphics.
TEXTBOOK / SPECIAL MATERIALS:
- Introduction to the HIM Profession
- Health Care Delivery Systems
- Content and Structure of the Health Record
- Electronic Health Record
- Healthcare Data Sets and Standards
- Clinical Vocabularies
- Health Information Function
- Secondary Data Sources
See bookstore website for current book(s) at https://www.dacc.edu/bookstoreEVALUATION:
The student's progress will be evaluated based on assigned projects, reports and examinations. A point system will be given to all classroom assignments, homework, attendance and examinations. There will be numerous reports using Internet search projects.
Exam and quizzes cover the text material, class discussions, and handouts.
There will be some group activities.
90 - 100 = A
80 - 89 = B
70 - 79 = C
60 - 69 = D
59 & below = F
This course addresses the following domains of knowledge identified by the
American Health Information Management Association as indicators of entry-level
competency for Health Information Technology. See the student handbook for a
complete list of domains and subdomains.
Domain I. Data Content, Structure & Standards
Subdomain I.A. Classification Systems
- Apply diagnosis/procedure codes according to current guidelines
- Evaluate the accuracy of diagnostic and procedural coding
- Apply diagnostic and procedural groupings
- Evaluate the accuracy of diagnostic/procedural groupings
Subdomain I.B. Health Record Content and Documentation
- Analyze the documentation in the health record to ensure it supports the
diagnosis and reflects the patient’s progress, clinical findings, and discharge
- Verify the documentation in the health record is timely, complete, and
- Identify a complete health record according to organizational policies,
external regulations, and standards
- Differentiate the roles and responsibilities of various providers and
disciplines to support documentation requirements throughout the continuum of
Subdomain I.C. Data Governance
- Apply policies and procedures to ensure the accuracy and integrity of health data
Subdomain I.D. Data Management
- Collect and maintain health data
- Apply graphical tools for data presentations
Subdomain I.E. Secondary Data Sources
- Identify and use secondary data presentations
- Validate the reliability and use secondary data sources
Domain II. Information Protection: Access, Disclosure, Archival, Privacy &
Subdomain II.A. Health Law
- Apply healthcare legal terminology
- Identify the use of legal documents
- Apply legal concepts and principles to the practice of HIM
Subdomain II.B. Data Privacy, Confidentiality & Security
- Apply confidentiality, privacy and security measures and policies and procedures for internal and external use and exchange to protect electronic health information
- Apply retention and destruction policies for health information
- Apply system security policies according to departmental and organizational
Subdomain II.C. Release of Information
- Apply policies and procedures surrounding issues of access and disclosure of protected health information
Domain III. Informatics, Analytics and Data Use
Subdomain III.A. Health Information Technologies
- Utilize software in the completion of HIM processes
- Explain policies and procedures of networks, including intranet and Internet
to facilitate clinical and administrative applications
Subdomain III.B. Information Management Strategic Planning
- Explain the process used in the selection and implementation of health
information management systems
- Utilize health information to support enterprise-wide decision support for strategic planning
Subdomain III.C. Analytics and Decision Support
- Explain analytics and decision support
- Apply report generation technologies to facilitate decision making
Subdomain III.D. Health Care Statistics
- Utilize basic descriptive, institutional, and healthcare statistics
- Analyze data to identify trends
Subdomain III.E. Research Methods
- Explain common research methodologies and why they are used in healthcare
Subdomain III.F. Consumer Informatics
- Explain usability and accessibility of health information by patients,
including current trends and future challenges
Subdomain III.G. Health Information Exchange
- Explain current trends and future challenges in health information exchange
Subdomain III.H. Information Integrity and Data Quality
- Apply policies and procedures to ensure the accuracy and integrity of health
data both internal and external to the health system
Domain IV. Revenue Management
Subdomain IV.A. Revenue Cycle and Reimbursement
- Apply policies and procedures for the use of data required in healthcare
- Evaluate the revenue cycle management processes
Domain V. Compliance
Subdomain V.A. Regulatory
- Analyze policies and procedures to ensure organizational compliance with
regulations and standards
- Collaborate with staff in preparing the organization for accreditation, licensure, and/or certification
- Adhere to the legal and regulatory requirements related to health information
Subdomain V.B. Coding
- Analyze current regulations and established guidelines in clinical
- Determine accuracy of computer assisted coding assignment and recommend
Subdomain V.C. Fraud Surveillance
- Identify potential abuse or fraudulent trends through data analysis
Subdomain V.D. Clinical Documentation Improvement
- Identify discrepancies between supporting documentation and coded data
- Develop appropriate physician queries to resolve data and coding discrepancies
Domain VI. Leadership
Subdomain VI.A. Leadership Roles
- Summarize health information related leadership roles
- Apply the fundamentals of team leadership
- Organize and facilitate meetings
Subdomain VI.B. Change Management
- Recognize the impact of change management on processes, people, and systems
Subdomain VI.C. Work Design and Process Improvement
- Utilize tools and techniques to monitor, report, and improve processes
- Identify cost-saving and efficient means of achieving work processes and
- Utilize data for facility-wide outcomes reporting for quality management and
Subdomain VI.D. Human Resources Management
- Report staffing levels and productivity standards for health information
- Interpret compliance with local, state, and federal labor regulations
- Adhere to work plans, policies, procedures, and resource requisitions in
relation to job functions
Subdomain VI.E. Training and Development
- Explain the methodology of training and development
- Explain return on investment for employee training/development
Subdomain VI.F. Strategic and Organizational Management
- Summarize a collection methodology for data to guide strategic and
- Understand the importance of healthcare policy-making as it relates to the
healthcare delivery system
- Describe the differing types of organizations, services, and personnel and
their interrelationships across the healthcare delivery system
- Apply information and data strategies in support of information governance
- Utilize enterprise-wide information assets in support of organizational
strategies and objectives
Subdomain VI.G. Financial Management
- Plan budgets
- Explain accounting methodologies
- Explain budget variances
Subdomain VI.H. Ethics
- Comply with ethical standards of practice
- Evaluate the consequences of a breach of healthcare ethics
- Assess how cultural issues affect health, healthcare quality, cost, and HIM
- Create programs and policies that support a culture of diversity
Subdomain VI.I. Project Management
- Summarize project management methodologies
Subdomain VI.J. Vendor/Contract Management
- Explain Vendor/Contract Management
Subdomain VI.K. Enterprise Information Management
- Apply knowledge of database structure and design
|STUDENT CONDUCT CODE:||Membership in the DACC community brings both rights and responsibility. As a student at DACC, you are expected to exhibit conduct compatible with the educational mission of the College. Academic dishonesty, including but not limited to, cheating and plagiarism, is not tolerated. A DACC student is also required to abide by the acceptable use policies of copyright and peer-to-peer file sharing. It is the student’s responsibility to become familiar with and adhere to the Student Code of Conduct as contained in the DACC Student Handbook. The Student Handbook is available in the Information Office in Vermilion Hall and online at: https://www.dacc.edu/student-handbook|
|DISABILITY SERVICES:||Any student who feels s/he may need an accommodation based on the impact of a disability should contact the Testing & Academic Services Center at 217-443-8708 (TTY 217-443-8701) or stop by Cannon Hall Room 103. Please speak with your instructor privately to discuss your specific accommodation needs in this course.|