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1 COURSE SYLLABUS HITT (2:2:0) Legal and Ethical Aspects of Health Information Health Information Technology Allied Health Technical Education Division Reese Center SOUTH PLAINS COLLEGE Fall 2011 *** Items on this syllabus are subject to change ***

2 South Plains College Reese Center Course Syllabus Course Title: HITT (2:2:0): Legal and Ethical Aspects of Health Information Semester: Fall 2010 Tuesday: 11:15-1:15 Location: RC516 Instructor: Mignon Brown (Adjunct Faculty) Phone: Office Hours: By appointment SOUTH PLAINS COLLEGE IMPROVES EACH STUDENTS LIFE ************************************************************* Course Description: This course introduces the concepts of confidentiality, ethics, health care legislation, and regulations relating to the maintenance and use of health information. Course Outcomes: The student, with 75% proficiency, will apply local, state, and federal standards and regulations for the control and use of health information; demonstrate appropriate health information disclosure practices; and identify and discuss ethical issues in health care. Course Goals: to prepare the student to understand the legal and regulatory environment of health care as illustrated by AHIMA s Domains, Subdomains, and Tasks: Course Objectives: At the conclusion of this course, the student with 75% proficiency, should be able to: A. Describe the basic sources of law, organization of federal government and Administrative Agencies that most affect the healthcare industry. (C15) B. Describe the American court system; trace legal proceedings both before and during the trial process. (C15) C. Understand the importance of legible, accurate and complete patient records. (C6, C7) D. Understand the concepts of medical malpractice, negligence, tort, duty and stand and of care. (C15) E. Identify the functions/uses of the patient record and the influence of law sources upon its content. (C3) F. Define a statute of limitations and explain how it impacts the development of record retention policies. (C3) G, Compare and contrast record destruction done in ordinary course of business and that done due to facility closure. (C11) H. Explain the property rights of the patient record/information and identify the elements of a valid release of information form. (F2, F5, F6, F7, F8, F12) I. Compare and contrast the rights of access of patient and third parties to patient-specific health information. (F17) J. Explain the interrelationship between confidentiality and privacy as well as the three

3 sources of law upon which the right of privacy is based. (F17) K. Discuss the concepts of informed consent, advance directive, the Patient Self- Determination Act, living wills and durable powers of attorney for health care. (F1) L. Describe the role of medical record practitioner and the use of the medical record in legal proceedings. (C15) M. Explain the nature and purpose of risk management and quality assurance and the role of the health information manager in each program. (C15) N. Understand the key retention, security and release concepts of HIV/AIDS and other specialized patient records. (F1,F17,C11) O. Discuss legal and ethical issues raised by automated medical record systems. (F17) P. Understand concepts of a personal and impersonal use of data. (C7) Course Competencies and Knowledge Clusters: SCANS AND FOUNDATION SKILLS are identified for specific course objectives. A complete listing with an explanation of these skills is attached at the back of the syllabus for your information. SCANS Competencies Learned Upon Successful Completion of this Course: C3, C5-6, C9, C15, C18, F1-3, F5-6, F8-12, F15, F17 AHIMA ENTRY LEVEL COMPETENCIES (called domains, subdomains, and tasks) define the skills needed for proficiency and employment as a Registered Health Information Technician (RHIT). AHIMA Competencies Learned Upon Successful Completion of this Course: III.A.1; III.A.2; III.A.3; III.B.1; III.B.2; III.B.3; III.B.4; III.B.5; III.B.6; and III.B.7 A complete list with explanations of these competencies is attached to the back of this syllabus for student review and consideration. HIM ASSOCIATE DEGREE LEVEL KNOWLEDGE CLUSTER CONTENT and COMPETENCY LEVELS Learned Upon Successful Completion of this Course: III.B.1; III.B.2; III.B.3; III.B.4; III.B.5; and III.B.6. A complete list with explanations of these knowledge cluster content and competency levels is attached to the back of this syllabus for student review and consideration. General Course Information: Textbooks: Law & Ethics for Medical Careers,by Karen Judson 4 th Edition Health Information: Management of a Strategic Resource 3 rd Edition and Study Guide by Mervat Abdelhak Class Attendance: Students are expected to be in class each time it meets. Punctual and regular class attendance is required of all students attending South Plains College. Students are responsible for all class work covered during absences from class. Whenever absences become excessive and, in the instructor s opinion, minimum course objectives cannot be met due to absences, the student will be withdrawn from the course. In addition, an instructor is required to initiate a student s administrative withdrawal when the student has missed every class during any fourteen consecutive calendar days period excluding holidays. Please see the College Catalog. 3 tardies = 1 absence,

4 Disabilities Statement: Students with disabilities, including but not limited to physical, psychiatric, or learning disabilities, who wish to request accommodations in this class should notify the Special Services Office early in the semester so that the appropriate arrangements may be made. In accordance with federal law, a student requesting accommodations must provide acceptable documentation of his/her disability to the Coordinator of Special Services. For more information, call or visit the Special Services Office in rooms 809 and 811, Reese Center Building 8, ext Diversity Statement: In this class, the teacher will establish and support an environment that values and nurtures individual and group differences and encourages engagement and interaction. Understanding and respecting multiple experiences and perspectives will serve to challenge and stimulate all of us to learn about others, about the larger world and about ourselves. By promoting diversity and intellectual exchange, we will not only mirror society as it is, but also model society as it should and can be. Grading Policy: Grading will be based on chapter related assignments and tests, a term paper and its oral presentation. Missed tests are the student s responsibility for make up. A comprehensive final exam will be given over all class lectures, handouts, and readings A 30% Mid-Term Exam B 20% Quiz Grades Average C 20% Research Paper D 30% Final exam < 60 F Term paper: A concept paper of 3-5 double spaced typed pages is to be prepared on a contemporary HIM legal issue. ( A 5-10 minute presentation will be made over this research. If a group project is selected the presentation length will be 10 minutes per person in the group.) An "A" level student will have regular attendance with no more than 2 absences during the semester; turn in the required term project on the date assigned; participate in class activities, such as discussions on assigned topics, assigned readings, and class notes; and take the assigned tests on the day they are given. Assignments: Assignments are to be done in sequence during the semester. All written work will be due as assigned. Assignments which are turned in after the due date, will drop a letter grade. Exams will be taken on the date assigned, in the classroom. Make up-exams will drop a letter grade. Make up exams will be taken within one week from the original exam date. Evaluation Criteria: The instructor will maintain a continuous record of each student s progress. Students must perform at a C level or better to successfully complete this course. Additional Information: VHS terminology tapes and other self-instruction materials are available in the SAC for those who need additional assistance. Library Resources: The Reese SPC library is located in Building 8. Computers, for student use, are located in the library. All students may also utilize the library on the Levelland Campus. With a SPC ID card, students may use the Texas Tech Library. SCANS COMPETENCIES C-1 TIME Selects goal relevant activities, ranks them, allocates time, prepares and follows schedules. C-2 MONEY Uses or prepares budgets, makes forecasts, keeps records and makes adjustments to meet objectives. C-3 MATERIALS AND FACILITIES Acquires, stores, allocates, and uses materials or space efficiently. C-4 HUMAN RESOURCES Assesses skills and distributes work accordingly, evaluates performances and provides feedback. INFORMATION Acquires and Uses Information C-5 Acquires and evaluates information. C-6 Organizes and maintains information. C-7 Interprets and communicates information. C-8 Uses computers to process information. INTERPERSONAL Works with Others

5 C-9 Participates as members of a team and contributes to group effort. C-10 Teaches others new skills. C-11 Serves Clients / Customers works to satisfy customer s expectations. C-12 Exercises Leadership communicates ideas to justify position, persuades and convinces others, responsibly challenges existing procedures and policies. C-13 Negotiates works toward agreements involving exchanges of resources; resolve divergent interests. C-14 Works with Diversity works well with men and women of diverse backgrounds. SYSTEMS Understands Complex Interrelationships C-15 Understands Systems knows how social, organizational, and technological systems work and operates effectively with them. C-16 Monitors and Corrects Performance distinguishes trends, predicts impacts on system operations, diagnoses systems performance and correct malfunctions. C-17 Improves or Designs Systems suggests modifications to existing systems and develops new or alternative systems to improve performance. TECHNOLOGY Works with a Variety of Technologies C-18 Selects Technology chooses procedures, tools, or equipment, including computers and related technologies. C-19 Applies Technology to Task understands overall intent and proper procedures for setup and operation of equipment. C-20 Maintains and Troubleshoots Equipment prevents, identifies, or solves problems with equipment, including computers and other technologies. FOUNDATION SKILLS BASIC SKILLS Reads, Writes, Performs Arithmetic and Mathematical Operations, Listens and Speaks F-1 Reading Locates, understands, and interprets written information in prose and in documents such as manuals, graphs, and schedules. F-2 Writing Communicates thoughts, ideas, information, and messages in writing and creates documents such as letters, directions, manuals, reports, graphs, and flow charts. F-3 Arithmetic Performs basic computations; uses basic numerical concepts such as whole numbers, etc. F-4 Mathematics Approaches practical problems by choosing appropriately from a variety of mathematical techniques. F-5 Listening Receives, attends to, interprets, and responds to verbal messages and other cues. F-6 Speaking Organizes ideas and communicates orally. THINKING SKILLS Thinks Creatively, Makes Decisions, Solves Problems, Visualizes and Knows How to Learn and Reason F-7 Creative Thinking Generates new ideas. F-8 Decision-Making Specifies goals and constraints, generates alternatives, considers risks, evaluates and chooses best alternative. F-9 Problem Solving Recognizes problems, devises and implements plan of action. F-10 Seeing Things in the Mind s Eye Organizes and processes symbols, pictures, graphs, objects, and other information. F-11 Knowing How to Learn Uses efficient learning techniques to acquire and apply new knowledge and skills. F-12 Reasoning Discovers a rule or principle underlying the relationship between two or more objects and applies it when solving a problem. PERSONAL QUALITIES Displays Responsibility, Self-Esteem, Sociability, Self-Management, Integrity and Honesty F-13 Responsibility Exerts a high level of effort and perseveres towards goal attainment. F-14 Self-Esteem Believes in own self-worth and maintains a positive view of self. F-15 Sociability Demonstrates understanding, friendliness, adaptability, empathy and politeness in group settings. F-16 Self-Management Assesses self accurately, sets personal goals, monitors progress and exhibits self-control. F-17 Integrity/Honesty Chooses ethical courses of action. AHIMA Associate Degree Entry-Level Competencies: Domains, Subdomains, and Tasks 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 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. Contribute to the definitions for and apply clinical vocabularies and terminologies used in the organization s health information systems. 5. 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. Report compliance findings according to organizational policy. 4. Maintain the accuracy and completeness of the patient record as defined by organizational policy and external regulations and standards. 5. Assist in preparing the organization for accreditation, licensing, and/or certification surveys. C. Subdomain: Clinical Classification Systems 1. Use and maintain electronic applications and work processes to support clinical classification and coding. 2. Apply diagnosis/procedure codes using ICD-9-CM. 3. Apply procedure codes using CPT/HCPCS. 4. Ensure accuracy of diagnostic/procedural groupings such as DRG, APC, and so on. 5. Adhere to current regulations and established guidelines in code assignment. 6. Validate coding accuracy using clinical information found in the health record. 7. Use and maintain applications and processes to support other clinical classification and nomenclature systems (such as ICD-10-CM, SNOMED, and so on). 8. Resolve discrepancies between coded data and supporting documentation. D. Subdomain: Reimbursement Methodologies 1. Apply policies and procedures for the use of clinical data required in reimbursement and prospective payment systems (PPS) in healthcare delivery. 2. Support accurate billing through coding, chargemaster, claims management, and bill

6 reconciliation processes. 3. Use established guidelines to comply with reimbursement and reporting requirements such as the National Correct Coding Initiative. 4. Compile patient data and perform data quality reviews to validate code assignment and compliance with reporting requirements such as outpatient prospective payment systems. II. Domain: Health Statistics, Biomedical Research, and Quality Management A. Subdomain: Healthcare Statistics and Research 1. Abstract and maintain data for clinical indices/databases/registries. 2. Collect, organize, and present data for quality management, utilization management, risk management, and other related studies. 3. Compute and interpret healthcare statistics. 4. Apply Institutional Review Board (IRB) processes and policies. 5. Use specialized databases to meet specific organization needs such as medical research and disease registries. B. Subdomain: Quality Management and Performance Improvement 1. Abstract and report data for facility-wide quality management and performance improvement programs. 2. Analyze clinical data to identify trends that demonstrate quality, safety, and effectiveness of healthcare. III. Domain: Health Services Organization and Delivery A. Subdomain: Healthcare Delivery Systems 1. Apply information system policies and procedures required by national health information initiatives on the healthcare delivery system. 2. Apply current laws, accreditation, licensure, and certification standards related to health information initiatives from the national, state, local, and facility levels. 3. Apply policies and procedures to comply with the changing regulations among various payment systems for healthcare services such as Medicare, Medicaid, managed care, and so forth. 4. Differentiate the roles of various providers and disciplines throughout the continuum of healthcare and respond to their information needs. B. Subdomain: Healthcare Privacy, Confidentiality, Legal, and Ethical Issues 1. Participate in the implementation of legal and regulatory requirements related to the health information infrastructure. 2. Apply policies and procedures for access and disclosure of personal health information. 3. Release patient-specific data to authorized users. 4. Maintain user access logs/systems to track access to and disclosure of identifiable patient data. 5. Conduct privacy and confidentiality training programs. 6. Investigate and recommend solutions to privacy issues/problems. 7. Apply and promote ethical standards of practice. IV. Domain: Information Technology and Systems

7 A. Subdomain: Information and Communication Technologies 1. Use technology, including hardware and software, to ensure data collection, storage, analysis, and reporting of information. 2. Use common software applications such as spreadsheets, databases, word processing, graphics, presentation, , and so on in the execution of work processes. 3. Use specialized software in the completion of HIM processes such as record tracking, release of information, coding, grouping, registries, billing, quality improvement, and imaging. 4. Apply policies and procedures to the use of networks, including intranet and Internet applications to facilitate the electronic health record (EHR), personal health record (PHR), public health, and other administrative applications. B. Subdomain: Data, Information, and File Structures 1. Apply knowledge of data base architecture and design (such as data dictionary, data modeling, data warehousing) 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. 3. Design and generate reports using appropriate software. 4. Maintain archival and retrieval systems for patient information stored in multiple formats. 5. Coordinate, use, and maintain systems for document imaging and storage. 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 trail and data quality monitoring programs. 5. Contribute to the design and implementation of risk management, contingency planning, and data recovery procedures. E. Subdomain: Healthcare Information Systems 1. Participate in the planning, design, selection, implementation, integration, testing, evaluation, and support for organization-wide information systems. 2. Use the principles of ergonomics and human factors in work process design. V. Domain: Organizational Resources A. Subdomain: Human Resources 1. Apply the fundamentals of team leadership. 2. Organize and contribute to work teams and committees. 3. Conduct new staff orientation and training programs. 4. Conduct continuing education programs. 5. Monitor staffing levels and productivity standards for health information functions, and provide feedback to management and staff regarding performance. 6. Communicate benchmark staff performance data. 7. Prioritize job functions and activities. 8. Use quality improvement tools and techniques to monitor, report and improve processes. B. Subdomain: Financial and Physical Resources 1. Make recommendations for items to include in budgets and contracts. 2. Monitor and order supplies needed for work processes. 3. Monitor coding and revenue cycle processes. 4. Recommend cost-saving and efficient means of achieving work processes and goals. 5. Contribute to work plans, policies, procedures, and resource requisitions in relation to job functions.

8 AHIMA Associate Degree Knowledge Cluster Content and Levels Biomedical Sciences Anatomy (4) Physiology (4) Medical Terminology (4) Pathophysiology (4) Pharmacotherapy (4) I.A. Health Data Structure, Content and Standards 1. Data versus information (4) 2. Structure and use of health information (individual, comparative, aggregate) (4) 3. Health information media (such as paper, computer, web-based) (4) 4. Health record data collection tools (such as forms, screens, etc.) (4) 5. Data sources (primary, secondary) (4) 6. Data definitions, vocabularies, terminologies, and dictionaries (4) 7. Data storage and retrieval (4) 8. Data quality and integrity (4) 9. Healthcare data sets (such as OASIS, HEDIS, DEEDS, UHDDS) (4) 10. Data monitoring and compliance reporting (5) 11. National Healthcare Information Infrastructure (NHII) (4) I.B. Healthcare Information Requirements and Standards 1. Type and content of health record (paper, electronic, computer-based, e-health-personal, web-based) (5) 2. Health record documentation requirements (such as accreditation, certification, licensure) (5) 3. Health record monitoring and compliance reporting (5) I.C. Clinical Classification Systems 1. Classifications, taxonomies, nomenclatures, terminologies, and clinical vocabularies (4) 2. Principles and applications of coding systems (such as ICD-9-CM, ICD-10, CPT/HCPCS, DSM-IV) (5) 3. Diagnostic and procedural groupings (such as DRG, APC, RUGs, SNOMED-CT) (5) 4. Casemix analysis and indexes (4) 5. Severity of illness systems (4) 6. Coding compliance strategies, auditing, and reporting (such as CCI, plans) (5) 7. Coding quality monitors and reporting (5) I.D. Reimbursement 1. Commercial, managed care and federal insurance plans (4) 2. Payment methodologies and systems (such as capitation, prospective payment systems PPS, RBRVS) (4) 3. Billing processes and procedures (such as claims, EOB, ABN, electronic data interchange) (4) 4. Chargemaster maintenance (5) 5. Regulatory guidelines (such as LMRP, peer review organizations) (3) 6. Reimbursement monitoring and reporting (5) 7. Compliance strategies and reporting (3) II.A. Healthcare Statistics and Research 1. Indices, databases and registries (4) 2. Vital statistics (5) 3. Healthcare statistics (5) 4. Descriptive statistics (such as means, frequencies, ranges, percentiles, standard deviations) (5) 5. Statistical applications with health care data (5) 6. Institutional Review Board (IRB) processes (4) 7. National guidelines regarding human subjects research (4) 8. Research protocol monitoring (4) 9. Data selection, interpretation, and presentation (5) 10. Knowledge-based research techniques (such as library, Medline, web-based) (5) II.B. Quality management and Performance Improvement 1. Quality assessment and improvement (such as process, collection tools, data analysis, reporting techniques) (4) 2. Utilization management, risk management, and case management (3) 3. Regulatory quality monitoring requirements (4) 4. Outcomes measures and monitoring (4) III.A. Healthcare Delivery Systems 1. Organization of healthcare delivery in the United States (4) 2. Healthcare organizations structure and operation (4) 3. External standards, regulations, and initiatives (such as licensure, certification, accreditation, HIPAA) (4)

9 4. Payment and reimbursement systems (4) 5. Healthcare providers and disciplines (4) III.B. Healthcare Privacy, Confidentiality, Legal and Ethical Issues 1. Legislative and regulatory processes (3) 2. Legal terminology (5) 3. Health information/record laws and regulations (such as retention, patient rights/advocacy, advanced directives, privacy) (5) 4. Confidentiality, privacy, and security policies, procedures, and monitoring (5) 5. Release of information policies and procedures (5) 6. Professional and practice-related ethical issues (5) IV.A. Information and Communication Technologies 1. Computer concepts (such as hardware components, operating systems, languages, software packages) (3) 2. Communication and Internet technologies (such as networks, intranet, standards) (3) 3. Common software applications (such as word processing, spreadsheet, database, graphics) (5) 4. Health information systems (such as administrative, patient registration, ADT, EHR, personal health record (PHR), lab, radiology, pharmacy) (4) 5. Voice recognition technology (3) 6. Health information specialty systems (such as ROI, coding, registries) (5) 7. Application of systems and policies to health information systems and functions and healthcare data requests (5) IV.B. Data Storage and Retrieval 1. Document archival, retrieval, and imaging systems (5) 2. Maintenance and monitoring of data storage systems (5) IV.C. Data Security and Healthcare Information Systems 1. System architecture and design (3) 2. System acquisition and evaluation (3) 3. Screen design (4) 4. Data retrieval and maintenance (4) 5. Data security concepts (3) 6. Data integrity concepts (4) 7. Data integrity and security processes and monitoring (5) 8. Data recovery and risk management (4) 9. Work process design (such as ergonomics, equipment selection) (3) V.A. Organizational Resources 1. Roles and functions of teams and committees (5) 2. Teams/consensus building and committees (4) 3. Communication and interpersonal skills (5) 4. Team leadership concepts and techniques (4) 5. Orientation and training (such as content, delivery, media) (5) 6. Workflow and process monitors (4) 7. Performance monitors (4) 8. Revenue cycle monitors (4) 9. Organizational plans and budgets (framework, levels, responsibilities, etc.) (4) 10. Resource allocation monitors (4) Competency Levels Explanation 1 = Awareness Introductory recall and recognition 2 = Literacy Knowledge of framework and content 3 = Concept Comprehension, translation, extrapolation and interpretation of meaning 4 = Detailed Appropriate application of knowledge in a structured or controlled context Understanding 5 = Skilled Use Application using analysis, synthesis, and evaluation in new situations

10 Course Schedule: Fall 2011 Lecture chapter and test each Tuesday. Research paper due 10/25/11. Mid-Term exam date to be announced. Additional Reading and Workbook Assignment: Chapters 15 Health Information: Management of a Strategic Resource and Study Guide, Mervat Abdelhak Part 1 The Foundations of Law and Ethics 1 Introduction to Law and Ethics 2 Working in Health Care 3 Law, the Courts, and Contracts Part 2 Legal Issues for Working Health Care Practitioners 4 Professional Liability and Medical Malpractice 5 Defenses to Liability Suits 6 Medical Records and Informed Consent 7 Privacy Law and HIPAA Part 3 Professional, Social, and Interpersonal Health Care Issues 8 Physicians' Public Duties and Responsibilities 9 Workplace Legalities 10 The Beginning of Life and Childhood 11 Death and Dying 12 Ethics for Health Care Practitioners Additional Assignments: Read and Complete Review Exercises for Chapter 15 in: Health Information: Management of a Strategic Resource and Study Guide, 3rd Edition Abdelhak, M.

11 Appendix A-1 Research Paper Guidelines Each student will write a research paper based upon the subject used for the oral classroom presentation. This paper is worth 20% of your total grade. The research paper is to be typed, double spaced, five (5) pages for the body of the paper, a cover sheet and a bibliography/reference citing sources utilized. Your research paper is due 10/25/11. A total of five points per day will be subtracted for each day late. Introduce and describe in detail your topic or issue. (include history, why formed, etc.) Discuss how your topic or issue would be positive and/or negative for healthcare What does the future hold for your topic or issue? What did the research and/or the experts say about the future? What is your opinion about this issue or topic? Defend your opinion. Structure: Grammar Spelling Typewritten Sentence structure Cover sheet Reference material: Books Periodicals Internet Format: This paper does not require footnotes. Minimum length of the paper is 2-3 pages double spaced. Cover page Body of paper 2-3 Full pages References Appendix A-2 Oral Classroom Presentation or Research or Term Paper (all the same) Each student will research and present to the class, information on a legal subject or issue related to HIM. Subject. This is worth 20% of your final grade. Please follow these guidelines: 1. On 10/25/2011 turn in paper. 2. You will determine the subject of your research with guidance from the instructor. 3. Your grade will be compiled from research content, grammar, and structure skills.

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