MANCHESTER COMMUNITY COLLEGE

Course Content Outline

Course Number: / HIM100 / Course Title: Introduction to Health Information Management
Department: / Allied Health / Effective Semester: Fall 2012
Program: / HIM / Date of this Revision: March 21, 2012
Theory Hours: / 3 / Lab Hours: Credits: 3
Prerequisites: / Placement into
ENGL 110 / Corequisites: None
Prepared by:Sandra Guy, RHIT, CCA, CHPA

Catalog Description

This course introduces principles of Health Information Management (HIM) including technological trends; function, content and structure of health records; regulatory and licensing agency requirements; analyzing data and managing information along with professional, ethical and legal issues specific to the field of HIM. Prerequisite: Placement into ENGL110.

Course Objectives

  1. Discuss the principles, practices, ethics and functions of the health information management profession.
  2. Monitor and track the purposes, uses and users of patient records.
  3. Define content and other pertinent requirements for acute care records mandated by the Joint Commission, Medicare Conditions of Participation, Department of Public Health and other accrediting, licensing and regulatory agencies.
  4. Explain basic knowledge of the organization and purposes of acute care, behavioral health, ambulatory, rehabilitation and long term care facilities and relevant data set requirements for each.
  5. Define automated and manual methods of maintaining a Master Patient Index and other indices and registries.
  6. Identify components of a retention schedule and for primary and secondary clinical information that are compliant with Federal and state guidelines.
  7. Describe requirements for maintaining confidentiality, privacy and security of storing paper records including disaster and recovery procedures for both paper and electronic patient information.
  8. Identify types of numbering and filing systems used to uniquely identify patient records and ensure efficient storage and retrieval of information.
  9. Describe the flow and processing of clinical information into a patient record and how that information is managed to prevent unauthorized access.
  10. Identify the data sets used in acute, ambulatory, long term and home health care.
  11. Explain the record completion function, quantitative and qualitative analysis, concurrent or retrospective review, and deficiency analysis.

Recommended Methods of Assessment

Assessment Method 1: Tests

Performance Criteria: Graded on the standard 100 point scale

Course Objective Using this Method

  1. Discuss the principles, practices, ethics and functions of the health information management profession.
  2. Monitor and track the purposes, uses and users of patient records.
  3. Define content and other pertinent requirements for acute care records mandated by the Joint Commission, Medicare Conditions of Participation, Department of Public Health and other accrediting, licensing and regulatory agencies.
  4. Explain basic knowledge of the organization and purposes of acute care, behavioral health, ambulatory, rehabilitation and long term care facilities and relevant data set requirements for each.
  5. Define automated and manual methods of maintaining a Master Patient Index and other indices and registries.
  6. Identify components of a retention schedule and for primary and secondary clinical information that are compliant with Federal and state guidelines.
  7. Describe requirements for maintaining confidentiality, privacy and security of storing paper records including disaster and recovery procedures for both paper and electronic patient information.
  8. Identify types of numbering and filing systems used to uniquely identify patient records and ensure efficient storage and retrieval of information.
  9. Describe the flow and processing of clinical information into a patient record and how that information is managed to prevent unauthorized access.
  10. Identify the data sets used in acute, ambulatory, long term and home health care.
  11. Explain the record completion function, quantitative and qualitative analysis, concurrent or retrospective review, and deficiency analysis.

Assessment Method 2: Assignments

Performance Criteria: Graded on the standard 100 point scale. Performance criteria will vary with each assignment

Course Objectives

  1. Discuss the principles, practices, ethics and functions of the health information management profession.
  2. Monitor and track the purposes, uses and users of patient records.
  3. Define content and other pertinent requirements for acute care records mandated by the Joint Commission, Medicare Conditions of Participation, Department of Public Health and other accrediting, licensing and regulatory agencies.
  4. Explain basic knowledge of the organization and purposes of acute care, behavioral health, ambulatory, rehabilitation and long term care facilities and relevant data set requirements for each.
  5. Define automated and manual methods of maintaining a Master Patient Index and other indices and registries.
  6. Identify components of a retention schedule and for primary and secondary clinical information that are compliant with Federal and state guidelines.
  7. Describe requirements for maintaining confidentiality, privacy and security of storing paper records including disaster and recovery procedures for both paper and electronic patient information.
  8. Identify types of numbering and filing systems used to uniquely identify patient records and ensure efficient storage and retrieval of information.
  9. Describe the flow and processing of clinical information into a patient record and how that information is managed to prevent unauthorized access.
  10. Identify the data sets used in acute, ambulatory, long term and home health care.
  11. Explain the record completion function, quantitative and qualitative analysis, concurrent or retrospective review, and deficiency analysis.

Outline of Topics:

Functions of the Health Record

Content and Structure of the Health Record

Electronic Health Records

Health Care Data Sets

Health Information Technology Functions

Secondary Data Sources

Cognitive Levels met by course (should be reflected in objectives and assessments):

Bloom’s Taxonomy of Cognitive Objectives: Six levels arranged in order of increasing complexity (1=low, 6=high): (Source: SUNY – Potsdam)

Knowledge: Recalling or remembering information without necessarily understanding it. Includes behaviors such as describing, listing, identifying, and labeling.

Comprehension: Understanding learned material and includes behaviors such as explaining, discussing, and interpreting.

Application: The ability to put ideas and concepts to work in solving problems. It includes behaviors such as demonstrating, showing and making use of information.

Analysis: Breaking down information into its component parts to see interrelationships and ideas. Related behaviors include differentiating, illustrating, comparing, and categorizing.

Synthesis: The ability to put parts together to form something original. It involves using creativity to compose or design something new.

Evaluation: Judging the value of evidence based on definite criteria. Behaviors related to evaluation include: concluding, criticizing, prioritizing and recommending.

Cognitive Levels met by course

I = Introduced E = Emphasized A = Comprehensive Assessment INF = Informally Assessed
Knowledge / Comprehension / Application / Analysis / Synthesis / Evaluation
A / E / E / A / E

Core Attributes met by course (college wide)

Human Relationship Skills: The application of values, collaboration skills, standards, and ethical judgment required for personal and professional interaction.

Communication Skills: The ability to express ideas and share knowledge in a clear, focused, and organized manner.

Critical Thinking: The ability to analyze, synthesize, and evaluate information in a logical and coherent manner.

Global Perspectives: The ability to examine a concept in contexts and from perspectives other than one's own.

Quantitative Reasoning: The application of computational methods and numerical data interpretation to solve problems.

Scientific Processes: The application of scientific methods to gain knowledge and examine the laws, theories, and processes of physical and biological phenomena.

Technical Skills: The theoretical and applied knowledge for career entry and continued professional development

Core Attributes met by course

I = Introduced E = Emphasized A = Comprehensive Assessment INF = Informally Assessed
Human
Relationship
Skills / Communication
Skills / Critical
Thinking / Global
Perspectives / Quantitative
Reasoning / Scientific
Processes / Technical
Skills / Study
Skills
E / E / A / E / E / E

AHIMA Domains and Subdomains:

I. Domain: Health Data Management

A. Subdomain: Health Data Structure, Content and Standards

1. Collect and maintain health data (such as data elements, data sets, and databases).

2. Conduct analysis to ensure that documentation in the health record supports the diagnosis and reflects the patient’s progress, clinical findings, and discharge status.

3. Apply policies and procedures to ensure the accuracy of health data.

4. Verify timeliness, completeness, accuracy, and appropriateness of data and data sources for patient care, management, billing reports, registries, and/or databases.

B. Subdomain: Healthcare Information Requirements and Standards

1. Monitor and apply organization-wide health record

documentation guidelines.

2. Apply policies and procedures to ensure organizational compliance with regulations and standards.

3. Maintain the accuracy and completeness of the patient record as defined by organizational policy and external regulations and standards.

4. Assist in preparing the organization for accreditation, licensing, and/or certification surveys.

II. Domain: Health Statistics, Biomedical Research and Quality Management

A. Subdomain: Healthcare Statistics and Research

1. Collect, maintain and report data for clinical indices/databases/registries to meet specific organization needs such as medical research and disease registries.

IV. Domain: Information Technology & Systems

B. Subdomain: Data, Information, and File Structures

1. Apply knowledge of database architecture and design (such as data dictionary) to meet departmental needs.

C. Subdomain: Data Storage and Retrieval

1. Use appropriate electronic or imaging technology for data/record storage.

2. Query and generate reports to facilitate information retrieval using appropriate software.

3. Apply retention and destruction policies for health information.

D. Subdomain: Data Security

1. Apply confidentiality and security measures to protect electronic health information.

2. Protect data integrity and validity using software or hardware technology.

3. Apply departmental and organizational data and information system security policies.

4. Use and summarize data compiled from audit trails and data quality monitoring programs.