1 HEALTH RECORD SYSTEMS - LECTURE & LAB Health Information Technology Program Course Number: John A. Logan College HIT 102 & 103 Kaskaskia College HITC 102 & 103 Shawnee Community College HIT 102 & 103 Hours of Lecture: 3 Hours of Lab: 2 Total Credits: 4 Semester/Year: Spring 2015 Prerequisite: Lecture Date/Time: Lab Date/Time: Location: Instructor: Texts: Introduction to Health Information Friday, 9:00 a.m. - 11:50 a.m. Friday, 12:30 p.m. 2:20 p.m. SICCM Building, HIT Lab Chris Froemling, RHIA, CCS Phone: (618) Sayles, Nanette B., Health Information Management Technology: An Applied Approach, 4 th Edition, American Health Information Management Association, 2013 ISBN Abdelhak, Mervat, Health Information: Management of a Strategic Resource, 4 th Edition, Elsevier, 2012 ISBN Course Descriptions: Health Record Systems - Study of content, format, evaluation and completeness of the medical record; licensing, accrediting and regulatory agencies; number systems; patient indexes, filing systems, and records retention, storage and retrieval. Health Record Systems Lab - This course allows the student the laboratory hands-on experience in evaluating content, format and completeness of actual medical records. Also, indicated in this lab is experience with numbering systems patient indexes, filing systems, and records retention, storage and retrieval. Computer experience will be utilized as a teaching method. Objectives: 1. List and discuss the functions of the admitting department in a health care institution and explain its relationship to the health information department. 2. Explain the steps required to fill out a UB-04 form. 3. Abstract health records for UB-04 completion and validation. 4. Explain the master patient index and its arrangement.
2 5. Explain the regulatory requirements of a cancer registry. Describe the process involved in data abstraction and reporting and its importance. 6. Understand and explain the billing process of a hospital. 7. Define and explain the purpose of quantitative, qualitative, and statistical health information analysis. 8. Analyze a health record for quantitative information. 9. Relate recent journal articles, regarding the profession and regulations, published in various health magazines (i.e., Journal of AHIMA, For the Record) to student peers. 10. Understand the job duties performed of an RHIT via an interview. 11. Explain regulatory requirements of The Joint Commission in relation to the health information department and other ancillary departments. 12. Describe the process of health record abstracting. 13. Abstract health information from the health record for research studies, reimbursement, indices, and compilation of registries. 14. Collect data on the quality of documentation in the health record. 15. Understand and generate various health record abstracting reports. 16. Understand the job duties performed of an ROI position via an interview. 17. Understand the principles of electronic health records. 18. Distinguish between data and information. 19. Demonstrate an understanding of health record form design, analysis and control. 20. Discuss factors and regulations affecting retention of health records. 21. Understand various filing systems including unit, serial-unit, serial, family numbering and social security numbering. Also, state the advantages and disadvantages of each and how to convert a filing system. 22. List types of filing equipment and discuss their appropriate use. 23. Determine and evaluate equipment needs for a health information department. 24. Demonstrate an understanding of filing systems, including terminal digit, and straight numerical. 25. List various methods for storing and retrieving health records. 26. Explain the record control process including requisitions, charge-out system, outguides, automated chart location, color coding, filing rules, and procedures and transportation. 27. Understand the process of microfilming health records. 28. Analyze various microfilming techniques for advantages and disadvantages. 29. Abstract health records for tumor registries. 30. Define and describe the following indexes: number, disease, procedure, and physicians. 31. Define and explain the concept of record linkage. 32. Explain computer operating systems, software applications, and computer hardware/peripherals and how these are used in health information departments. 33. Discuss steps to ensure healthcare data integrity. 34. Discuss the types of computer systems/networks found in health care facilities. 35. Discuss and apply health record computer applications. 36. Discuss healthcare safeguards to data security. 37. Describe the functions of tumor registries and other specialized health information registries. 38. Discuss health record products with vendors and evaluate the service and product.
3 Course Grading Scale: Percentages Points (500 possible) A A B B C C D D E E Please note--there will be one grade assigned based on the above course grading scale. Your lab and lecture grade will be the same. Progression in the HIT program requires that the student earn a grade of C or better in this course. Grades of D or E are considered failing. If a student fails this course, it must be repeated with a passing grade of A, B, or C in order to continue in the HIT program. HIT courses are only offered once a year, so the student will have to wait to take the course until the following spring. All courses must be taken in sequence as specified by course pre-requisites unless permission is granted by the program director. Exams: There will be 3 unit examinations and a comprehensive final examination at the end of the semester. Each exam is worth 100 points for a total of 400 points. Tests results will be reviewed in class but the students will not be allowed to keep the tests. If a student misses an exam he/she may make it up with the exam grade automatically dropped one letter grade. However, if prior notification is given, the exam may be taken early with no penalty. Absenteeism Policy: Each student is expected to attend all class meetings. The student is expected to be on time and ready to begin class with the proper materials at the beginning of each class period. Arrivals after class has begun will be counted as present, but tardy. Three occurrences of tardiness will be counted as one absence. Students that have three absences will have their course grade dropped by one letter grade. Five absences will result in the student being dropped from the course. Student Support Services: Student support services are available at every college represented within the SICCM HIT program. Services are available for students with a disability for a wide variety of needs (i.e. tutors, note takers, interpreters, untimed testing) and are described in the college catalogs and student handbooks. Information and referral may also be obtained from the HIT Program Director. Cell Phones: Cell phones are prohibited during classroom instruction. If a student has a special circumstance that requires a cell phone to be on during class, the instructor must be notified and give prior approval. Students have breaks between classes to use their cell phones Academic Integrity: This class is subject to the college s Academic Integrity policy. All submitted work must be your own. Cheating and plagiarism will not be tolerated. Any student found in violation of this policy will be subject to SICCM disciplinary action (see student handbook) and disciplinary action as outlined in the campus Academic Integrity policy. Equal Educational Opportunity: The Colleges are committed to providing equal educational opportunities for all persons without regard to race, color, religion, sex, age, national origin, or disability.
4 Assignments/Projects: Read assigned chapters in texts and handouts. The following is a list of projects that will be assigned in the class. These are worth a total of 100 points. Please note that one point will be deducted for each typo, misspelling, or grammatical error submitted on written reports. Oral reports 3 reports at 3 points each + 1 point for doing all 3 10 points No make ups. You do not need to prepare a written report. Recommend using Journal of AHIMA, For the Record, ADVANCE for Health Information Professionals, or other relevant healthcare magazine. Several magazines are available in the classroom closet. You may elect to use a relevant online article. If you choose an online article, come prepared with two articles in the event that another student has selected the same article. Online links: ADVANCE (http://health-information.advanceweb.com) For the Record (http://fortherecordmag.com) Journal of AHIMA (http://journal.ahima.org) Interview an RHIT 2 page typed double spaced paper 10 points (1 inch margins, Times New Roman Font Size 12) Interview an ROI clerk 2 page typed double spaced paper 10 points (1 inch margins, Times New Roman Font Size 12) Conversion of filing system 10 points Copy machine 5 points File room floor plans 5 points UB-04 5 points Deficiency analysis 5 points Cancer Registry abstracts 10 points Failure of an EHR system 10 points The Joint Commission paper 20 points Total points 100 points The schedule and procedures in this course may be subject to change in the event of extenuating circumstances.
5 HEALTH RECORD SYSTEMS - LECTURE & LAB Spring 2015 DATE: January 9, 2015 LECTURE TOPICS AND ASSIGNMENTS Introduction to course & mentoring program ASSIGN: RHIT & ROI Interviews ASSIGN: Conversion of filing system project ASSIGN: Copy Machine project ASSIGN: File room floor plan project ASSIGN: The Joint Commission project FILM: Virtual department tour LECTURE: UNIT 1 Sayles pgs Handouts from Abdelhak 3 rd edition & Huffman January 16, 2015 LECTURE: Continue Unit 1 January 23, 2015 LECTURE: Continue Unit 1, Begin Unit 2 LAB: Consolidation of Duplicate Accounts Demo DUE: Journal Reports January 30, 2015 FIELD TRIP: Data Lock in Mt. Vernon at 10:00 EXAM: TEST 1 February 6, 2015 REVIEW: Test 1 LECTURE: UNIT 2 - Abdelhak pgs (indexes and registries), (forms), (data quality management) Sayles pgs , , (indexes and registries), , (forms), (data quality management) Handouts, DUE: Conversion of filing system DUE: Copy machine project DUE: File room floor plan ASSIGN: Cancer Registry abstracts LAB: Lab Plate Review February 13, 2015 LECTURE: Continue Unit 2 DUE: RHIT interview paper SPEAKER: Judy McClure, CTR, RHIT (12:15 2:20) Marion VA Medical Center Cancer Registry February 20, 2015 LECTURE: Continue Unit 2 DUE: Cancer Registry abstracts DUE: Journal Reports REVIEW: RHIT interview paper REVIEW: Assignments from 2/6 FILM: Electronic Health Records (28 min)
6 February 27, 2015 EXAM: TEST 2 REVIEW: Cancer Registry abstracts SPEAKER: Donna Young, RHIA, CCS (12:20 2:20) Memorial Hospital of Carbondale HI Manager Subject: Birth certificates March 6, 2015 REVIEW: Test 2 DUE: ROI interview paper SPEAKER: Nickie Fuhrhop, RHIT, CHP (12:20 2:20) IT System Analyst Subject: SIH ChartMaxx & Meditech systems LAB: VA CPRS system March 13, 2015 No class Spring Break March 20, 2015 LECTURE: UNIT 3 Handouts on UB-04, ABN, RFI & RFP, Abdelhak pgs , , , & Chapter 8 (& chapters 5 & 7 for reference) Sayles pgs , , , 567, , , , , & ASSIGN: UB-04 project REVIEW: ROI Interview paper March 27, 2015 LECTURE: Continue Unit 3 ASSIGN: Deficiency analysis project FILM: It s Everybody s Job, 14 min. LAB: McKesson Deficiency Analysis software April 3, 2015 No class - Holiday April 10, 2015 LECTURE: Continue Unit 3 ASSIGN: Failure of an EHR System DUE: Journal Reports DUE: UB-04 project April 17, 2015 LECTURE: Continue Unit 3 DUE: Deficiency analysis project REVIEW: UB-04 project FILM: Data Mining (25 min) April 24, 2015 EXAM: TEST 3 DUE: Failure of an EHR System DUE: The Joint Commission project & Extra Credit REVIEW: Deficiency analysis project May 1, 2015 LECTURE: Personal Health Record, Abdelhak pgs , & Sayles pgs , REVIEW: Test 3 & Semester tests for Final Exam May 8, 2015 TEST: COMPREHENSIVE FINAL Review: The Joint Commission project
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