HEALTH INFORMATION TECHNOLOGY PROGRAM. HITT 1301 HEALTH DATA CONTENT AND STRUCTURE/Hybrid/CRN: Spring 2011

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1 HEALTH INFORMATION TECHNOLOGY PROGRAM HITT 1301 HEALTH DATA CONTENT AND STRUCTURE/Hybrid/CRN: Spring 2011 Syllabus is subject to change at the discretion of the instructor. Carolyn Stariha, RHIA Office: Suite 519, Office 517 Telephone: Digital pager: Office Hours: Monday Thursday 2:00 p.m.- 4:00 p.m. or Student Conferences by appointment. Course Description: Introduction to system and processes for collecting maintaining and disseminating primary and secondary health related information. Introduction in delivery and organizational structure to include content of health record, documentation requirements, registries, indices, licensing, regulatory agencies forms, and screens. Course Objectives: AHIMA DOMAINS, SUBTASKS, AND TASKS for the Registered Health Information Technician I. Domain: Healthcare Data A. Subdomain: Data Structure, Content and Use 1. Verify timeliness, completeness, accuracy, and appropriateness of data and data sources 2. Conduct qualitative analysis to assure that documentation in the health record supports the diagnosis and reflects the progress, clinical findings, and discharge status II. Domain: Health Information Analysis 1. Abstract records for department 5. Present data in verbal and written forms 1

2 III. Domain: Healthcare Environment Healthcare Information Requirements and Standards Assist in developing health record documentation Perform quantitative analysis of health records to evaluate compliance with regulations and standards Perform qualitative analysis of health records to evaluate compliance Assist in preparing the facility for an accreditation, licensing, and/or certification survey Ensure facility-wide adherence to health information services compliance with regulatory requirements Domain: Information Technology & Systems Subdomain: Health Information Systems Collect and report data on incomplete records and Timeliness of record completion 1. Maintain filing and retrieval systems for paper-based patient records Maintain integrity of master patient/client index Maintain integrity of patient numbering and filing systems Design forms, computer input screens & other health record documentation tools Course Goals: *US Department of Labor, Secretary s Commission on Achieving Necessary Skills 1. Trace the history of medical record management and describe the evolution of healthcare. 2. Discuss the health information profession, code of ethics, and organizational structure. 3. Define the term (health record), understand its purpose, uses, and the content therein. 4. Identify regulatory bodies that impact health record documentation. 5. Analyze health records qualitatively and quantitatively. 2

3 6. Describe advantages and disadvantages of the filing, storage, and retention methods. Describe the filing systems. 7. Collect data on the quality of documentation in the health record. 8. Collect data on the status of incomplete records. 9. Identify design rules for data collection forms. 10. Describe construction considerations that must be made for paper forms. 11. Describe the function of indexes and registries, the way in which data is collected, and the types which must be maintained. Scans Competencies: 1. F1 Reading, F2 Writing, F3 Listening, F10 Seeing things in the minds eye, C5 Acquires and Evaluates Information. 2. F1 Reading, F2 Writing, C9 Participates as a member of a team, F12 Reasoning. 3. F12 Reasoning, F1 Reading, F2 Writing, C5 Acquires and Evaluate. 4. F12 Reasoning. 5. C7 Interprets and communicates information. 6. F12 Reasoning, Acquires and Evaluates Information, F9 Problem Solving. 7. C7 Interprets and communicates information. 8. F8 Decision Making, C7 Interprets and Communicates. 9. F12 Reasoning, F9 Problems Solving. 10. C5 Acquires and Evaluates Reasoning. Textbook Reference: -Health Information Management Technology, 3 rd Edition-Merida Johns -Health Information: Management of a Strategic Resource, 3 rd or Current Edition-Abdelhak, Grostick, Hankens, & Jacobs. -Professional Review Guide, PRG, 2010 Edition or Current Edition -Comprehensive Review Guide for Health Information RHIA & RHIT Exam Prep-Tyson-Howard & Thomas Handouts given by instructor. Class Time: Wednesday (4:00pm-7:00pm) 3

4 Class Requirements: 1. Read the assignments outlined on the attached schedule. 2. Turn in assignments at the beginning of class. 3. Have necessary materials in class. 4. Participate in class and group exercises. Course Methodology: Lecture Group Assignments Guest Lecture Tours Videos Exams: Exams are multiple choice, true and false, fill in the blank, matching and essay ( questions). There will be approximately 5 exams including the mid-term and the final. Exams need to be taken on the date assigned. Make-up exams may not be taken for the Mid-term or Final Exams. All make-up exams must be approved by the instructor and 20 points will be deducted from each make-up exam. Exams must be taken at the Coleman College from (4:00pm until 5:30pm). All students will be expected to be finished with their exam by 5:30 pm. Mid-term and Final exam must be taken at the Coleman College from (4:00 pm until 7:00 pm). ****Please Note: All assignments, group project participation assignments, and all homework assignments are due on the dates stated. No late work will be excepted unless prior arrangements have been made with the instructor. If you do not turn in your assignments, group project assignments, and homework on time then you will receive an automatic F. Late assignments accepted with the approval of the instructor will have 20 points deducted each day that the assignment is late and after 3 days late then the late assignment will not be accepted. 4

5 Houston Community College System seeks to provide equal education opportunities without regard to race, color, religion, national origin, sex, age, or handicap. This policy extends to employment, admission, and all programs and activities supported by the college." ADA STATEMENT: Any student with a documented disability (e.g. physical, learning, psychiatric, vision, hearing, etc.) who needs to arrange reasonable accommodations must contact Dr. Raj Gupta, Disability Services Office at (713) at the beginning of each semester. Faculty is authorized to provide only the accommodations requested by the Disability support services office. NOTICE: Students who repeat a course for a third or more time may soon face significant tuition/see increases at HCC and other Texas public colleges and universities. Please ask your instructor/counselor about opportunities for tutoring/other assistance prior to considering course withdrawal or if you are not receiving passing grades. HCC COURSE WITHDRAWAL POLICY The State of Texas has begun to impose penalties on students who drop courses excessively. For example, if you repeat the same course more than twice, you have to pay extra tuition. Beginning in Fall 2007, the Texas Legislature passed a law limiting students to no more than SIX total course withdrawals throughout their educational career in obtaining a certificate and/or degree. To help students avoid having to drop/withdraw from any class, HCC has instituted an Early Alert process by which your professor will alert you and counselors that you might fail a class because of excessive absences and/or poor academic performance. You should visit with your professor or a counselor to learn about what, if any, HCC interventions might be available to assist you online tutoring, child care, financial aid, job placement, etc. to stay in class and improve your academic performance. If you plan on withdrawing from your class, you MUST contact a counselor or your professor prior to withdrawing (dropping) the class and this must be done PRIOR to the withdrawal deadline to receive a W on your transcript. **Final withdrawal deadlines vary each semester and/or depending on class length, please visit the online registration calendars, HCC schedule of 5

6 classes and catalog, any HCC Registration Office, or any HCC counselor to determine class withdrawal deadlines. Remember to allow a 24-hour response time when communicating via and/or telephone with a professor and/or counselor. Do not submit a request to discuss withdrawal options less than a day before the deadline. If you do not withdraw before the deadline, you will receive the grade that you are making in the class as your final grade. ATTENDANCE POLICY Students taking Internet courses complete weekly assignments at their own computers and communicate with their instructor by electronic mail and other provided web-based technologies. Students complete assignments, take tests, and complete all other coursework just as they would in an on-campus class. Instructor will have weekly on-line chats with students. Course work will be submitted via the internet. Students must be in attendance on campus for appointed times and major exams. Students who are absent more than three class sessions will be administratively dropped from the course without notification. Exceptions to this policy will be up to the discretion of the instructor. The instructor checks attendance weekly. The instructor is required to report all absences for all students receiving financial aid (grants, VA, Social Security, etc.) It is the responsibility of the student to formally withdraw from a class not the instructor. Counselor- Dr. Ruj Gupta (713) Tutor- Ms. Sheridan (Hours are listed outside of the HITT Lab on the 5 th floor, Room 538). Academic Success Center-Ms. Alvarez-(713) Academic Dishonesty will not be tolerated. Exams and assignments are individual assignments. Plagiarized and copied papers will be handled in accordance with established HCCS college policy. Do not copy the work of other professionals. 6

7 Grading Policy: Homework/Class Assignments 4% Journal Assignment 3% HIM Interviews 4% Team Research Report/Group Participation 5% Medical Record Design 4% Quizzes 16% Individual Projects 5% (All of the above assignments are worth 31% of your grade) Tests (including Mid-term) 36% Final Exam 23% NO Make-Up Examinations for the Midterm and/or Final Grading Scale A B C Below F The letter grade of D cannot be earned in the Health Information Technology Program Test Score Sheet Students in the Health Information Technology Program may not keep test, nor test results that have been taken within the program. Upon receiving test outcomes, students must record their test scores on the following score sheet. This document will serve as a permanent record for your test scores. Date of Examination Name or Number of Test Student Test Score 7

8 Cover Sheet: All assignments must have a coversheet. Assignments turned in without a coversheet will result in points being deducted. The cover sheet must be centered on the sheet of paper and must include the following: Student s Name Student s ID # Class Name and Class CRN # Assignment Title Date Due Instructor s Name JOURNAL ASSIGNMENT: Students are to prepare at least a two (2) page, doubled spaced typed summary. One of the following Health Information Journals must be utilized The American Health Information Management Association Journal, Advance, or For the Record. A copy of the article must be attached to the summary. The student must include a Cover Sheet & a Works Cited Page. Submit assignment via Blackboard. Date Due: February 16, 2011 GROUP PARTICIPATION: Each student is to be assigned to a group at the beginning of the semester. Class projects, assigned presentations, and specific homework assignments will be completed in groups. HOMEWORK: Assignments are listed under the objectives. Students must answer all questions. Also, additional assignments will be given. Homework is due as assigned. No late homework will be accepted. Submit assignment via Blackboard. HIM INTERVIEWS: Each student will interview a credentialed Health Information practitioner (RHIA, RHIT, CCS) of the students choice. Students must notify practitioners to schedule the interview. Interviews need to be done in person not by phone, faxes, or . Students will be given 5 questions to ask at their interview. The student will need to make-up 5 questions of their own 8

9 to ask at the interview. The interview is 4% of your grade. Interview questions and answers must be submitted to the instructor on the date they are due. Be sure to include the practitioner s name, title, place of business, and phone number. Students are not allowed to interview practitioners at the same time. This is an individual project and should be treated as such. Students will present questions to the class. Practitioners should be someone other than the student's preceptor for the Practicum I. Submit assignment via Blackboard. Submit assignment via Blackboard. Date Due: March 2, 2011 TEAM RESEARCH REPORT: Each team is to report on the assigned specific topic. Students are at liberty to research any related journals, books, the internet, magazines, etc. Students may also interview professionals in the field. Creativity is strongly encouraged. Please include a bibliography or works cited page with your report. All team members must participate in the presentation and preparation of the assignment. Research papers should be at least 10 pages in length excluding cover page, double-spaced, 12 font only, and Times New Roman type. Include at least 5 resources with only 2 resources from the internet. A Work Cited page must be included with your report. All presentations should have a visual aid. Power-points, posters, and other visual displays must be presented at our presentation. Do not plagiarize. Date Due: April 27, 2011 Team1: The evolution, from the medical records to health information. Be sure to include information regarding HIPAA and the importance of Privacy and Security of Health Records. Also, include information about the electronic medical record. What are the advantages and disadvantages of an Electronic Record? Team 2: The evolving job functions of the Health Information Professional. Be sure to include past job functions and present job functions such as the Privacy Officer. Also, review all of the credentials which AHIMA offers. Why is being credentialed important? After a student graduations, what is the procedure for taking the RHIT Certification? 9

10 Team 3: The future of the Health Information Profession. How is the electronic record changing Health Information Technology? Where is the future of HIM going? How will the electronic record affect the future? How will Universal Health Care affect health care in general and the HIM profession? Include information about the Health Care Reform, HI-Tech Act, and Stimulus Act. An interview with a professional in Health Information would be great for this presentation. MEDICAL RECORD DESIGN: Each student will design a Medical Record. The medical record will reflect a made-up patient and made-up physician. The medical record will include a face sheet, History & Physical, Discharge Summary, and at least 5 entries of progress notes. You will type all reports to reflect the patient s history, diagnosis, and prognosis. Do not copy a record from your employer or place of practicum. This is a breech of confidentiality. This information needs to be completed in your own words. Refer to your textbooks for examples of forms. Submit via blackboard. Date Due: April 13, 2011 RECORD ANALYSIS: Each student will analyze three (3) charts for deficiencies. Date Due: Charts will be analyzed in class after your Final Exam. QUIZZES: Students will be quizzed weekly over the assigned readings. INDIVIDUAL PROJECTS: Each student will be assigned a Health Information topic. Students will present their topic to the class. The student needs to have a visual aid such as a powerpoint, poster, handouts, etc. The presentations should be 10 to 15 minutes in length. The report should have a cover sheet, 5 pages of information discussing the topic, and a bibliography or works cited page. The student must have at least three references with only 1 from the internet. Student will need to test fellow students knowledge of information by presenting an exam with at least 10 (ten) pages. Due Date: April 6,

11 HITT 1301 Health Data Content and Structure Spring 2011 SCHEDULE (Monday) **Jan 19 Jan 26 **Feb 2 **Feb 9 Introduction to Course Evolution of Health Care and Health Information Quiz 1-(Jan 27-Feb 1, 2011) Forms Design/Ethics in Healthcare Quiz-2-(Feb 3-Feb 8, 2011) Exam I (Covers information from Jan 26th). Evolution of Health Care and Health Information). Exam will be taken at the Coleman College. **Flow of the Health Record/Health Record Content/Ethics in Health Care Quiz 3-(Feb 10-Feb 15, 2011). Feb 16 Feb 23 **March 2 Journal Assignment Due Format Types/Management of Health Record Documentation Quiz 4-(Feb 17 Feb 22, 2011) Exam II (Covers information from February 2, 2011)-(Forms Design & Ethics) Exam will be taken via blackboard) (Flow of the Health Record /Health Record Content/Format Types/Management of Health Record Documentation) Filing and Numbering Systems/Record Storage and Retention/Record Problems/ Quiz 5-(March 3-March 8, 2011). Due: HIM Interviews 11

12 **March 9 Exam III (MID-TERM) will cover information From January 26, 2011-February 23, 2011 Group Preparation Day March 16 March 23 Spring Break Index and Registries Quiz 6-(March 24 March 29, 2011) **March 30 Filing and Numbering Systems/Record Storage and Retention/Record Problems/Index and Registries **April 6 **April 13 **April 20 **April 27 **May 4 Due: Individual Projects Tumor Registry (Guest Speaker) Exam 4 will cover information March 2 & March 23, 2011). (Filing and Numbering Systems/Record Storage And Retention/Record Problems/Indexes and Registries) Due: Medical Record Design Electronic Medical Record Quiz 7-(April 14-April 19, 2011) Tour Group Presentations Electronic Medical Record Quiz 8-Lesson 9 Final Exam (Comprehensive) 12

13 Health Information Technology HITT 1301 Health Data Content and Structure Objectives: Mastery of all objectives will be demonstrated by student obtaining at least 75% accuracy rate on written exams. Lesson 1- Due: February 9, 2011 Evolution of Health Care and Health Information. READING ASSIGNMENT Abdelhak Ch. 1, 2, & 8 pages Johns Ch. 1 & Ch. 2 Handouts Homework Assignment: Worksheet Answer the following questions. The student will: Trace evolution of the following: Health care in the United States, Joint Commission on Accreditation of Health Care Organizations (JCAHO), and the American Health Information Management Association (AHIMA). Know the essential characteristics of a hospital. Discuss the health care consumer. Know regulatory agencies and Department of Health and Human Services. Know the purpose, value, uses, and responsibility of the health record. Know the educational requirements for the RHIA and RHIT. Know the continuing education requirements for the RHIA and RHIT. Understand the Health Information practitioner roles in the work place. Lesson 2- February 2, 2011 Forms Design and Ethics in Health Care READING ASSIGNMENT Abdelhak- Ch. 2, pages 58-60; Ch. 4, pages JOHNS Ch. 8 (p ), Ch. 13, Ch. 14 Handouts Homework Assignment: Worksheet & The student will answer the following questions. 13

14 The student will: Know the purpose of forms. List the basic rules to be considered in forms design. Know the members of the forms or views team. Know why the forms or view team exist. Know and understand all special considerations for computer forms design. List the objectives of forms control. Understand forms control. Know and understand forms analysis, inventory, identification, and purchasing. Understand why forms are reviewed. What does an ethic mean? What is ethical and what is not ethical? Know and Understand AHIMA s Code of Ethics and Bylaws. Name some unethical things that a health information professional can do. Lesson 3- Due: February 16, 2011 Flow of the Health Record/Health Record Content/Ethics in Health Care READING ASSIGNMENT ABDELHAK- Ch. 3 & 4 Johns Ch.3 Handouts Homework Assignment: Worksheet & The student will answer the following questions. Student Will: Know and understand the professional code of ethics. Health Record Flow Student Will: Trace the flow of the medical record. Know documents generated by the medical service, nursing service, and ancillary services. List, understand, and know administrative data. List, understand, and know clinical data. Know report guidelines and time limits. 14

15 Lesson 4- Due: February 23, 2011 Format Types/Management of Health Record Documentation READING ASSIGNMENTS ABDELHAK Ch. 4 pages Johns Ch. 2 & Ch. 5 Handouts Homework Assignment: Worksheet & The student will answer the following questions. Define, understand, and know problem oriented, source oriented, and integrated medical record. Know the advantage and disadvantage of each. Define SOAP. Lesson 5- Due: February 23, 2011 Management of Health Information READING ASSIGNMENT ABDELHAK Ch. 4, pages Johns Ch. 8 & Ch. 15 Handouts Homework: Worksheet & The student will answer the following questions. The student will know: Know documentation requirements. Understand the different types of analysis. Understand documentation requirements by JCAHO. Know the components of Quantitative and Qualitative Analysis. Know and understand potentially compensable events. Know and understand incomplete and delinquent medical records. 15

16 Lesson 6- Due: March 2, 2011 Filing and Numbering Systems READING ASSIGNMENT ABDELHAK - CHAPTER 7 Johns Ch. 8 Handouts Homework Assignment- Worksheet & The student will answer the following questions. The student will know: Know and Understand the different filing systems. Know and Understand the different Numbering Systems. Know and Understand the advantages and disadvantages of each. Know Centralization and Decentralization. Understand the elements of Record Control. Understand the elements of Record Retention. Lesson 7- Due March 23, 2011 Indexes and Registers READING ASSIGNMENT ABDELHAK-Chapter 7 Johns Ch. 9 Handouts Homework: Worksheet & The student will answer the following questions: Student will know: Define Index. Define Register. Understand and know the Master Patient Index. What is the content and arrangement? Understand and know the Number Index. What is the content and Arrangement? Understand and know the Disease and Operation Index. What is the content and arrangement? Know uses of Indexes. Know the uses of automated and manual indexes. Know the different types of indexes and their uses. Know the different types of registers and their uses. 16

17 Know and Understand Database Management, Case Eligibility, Casefinding, Abstracting, Coding, Staging, automation, and uses of the discussed registries. i.e., AIDS, Diabetes, Birth Defects etc. Lesson 8- Due April 27, 2011 Electronic Medical Record READING ASSIGNMENT ABDELHAK-Chapter 5 Johns Ch. 4, 15, 16, & 17 Handouts Homework: The student will answer the following questions: Student will know: -Understand the concept and evolution of the electronic health record (EHR). -Identify and define terms associated with EHRs. -Relate the various initiatives local, regional, and national adoption of the EHR and health information technology. -Discuss the EHR challenges and the supporting roles of health information management professionals in addressing them, especially with respect to privacy, security, and legal aspects. -Develop an appreciation for the planning and implementation aspects of EHRs. -Provide examples of EHR systems as they may be implemented in various types of care settings. -Discuss clinician and other user needs in an electronic health record environment. -Identify common health information management operational issues in a hybrid and electronic health record environment. -Identify resources and strategies needed by health information management professionals to lead and participate in electronic health record projects. Lesson 9: Due April 20, 2011 Comprehensive Review Guide for Health Information RHIA & RHIT Exam Prep -Students need to read Ch. 1 -Student needs to read Ch. 2 and complete pp CD-Rom complete Ch. 2 assignment 17

18 Health Information Technology HITT 1301 Data Content and Structure Individual Projects 1. Organizational Charts (Lab Assignment 1-1) p.1 2. Administrative & Clinical Records (Lab Assignment 4-1) p AHIMA Professional Code of Ethics (Lab Assignment 2-4) p Proper Documentation Guidelines (Lab Assignment 4-2) p Chart Assembly (Types of Record Design) (Lab Assignment 5-1) p Quantitative & Qualitative Analysis of Patient Records. (Lab Assignment 5-2) p Forms Design (Lab Assignment 5-3) p Straight Numeric & Terminal Digit Filing (Lab Assignment 6-1) p Case Abstracting (Master Patient Index, Disease, Procedure, & Physician Index) (Lab Assignment 7-1 & 7-2, pp. 67 & 72) 10. Health Information Management Professionals: Credentials, HIM Career Opportunities, Professional Organizations. 18

19 11. Patient Record Formats (Advantages & Disadvantages) 12. Record Storage Methods including Filing equipment 13. Electronic Record 14. Numbering Systems 15. Traditional Paper-Based Record 19

20 Health Information Technology HITT 1301 Health Data Content & Structure Group Assignments Team1: The evolution, from the medical records to health information. Be sure to include information regarding HIPAA and the importance of Privacy and Security of Health Records. Also, include information about the electronic medical record. What are the advantages and disadvantages of an Electronic Record? Team 2: The evolving job functions of the Health Information Professional. Be sure to include past job functions and present job functions such as the Privacy Officer. Also, review all of the credentials which AHIMA offers. Why is being credentialed important? After student graduations, what is the procedure for taking the RHIT Certification? 20

21 Team 3: The future of the Health Information Profession. How is the electronic record changing Health Information Technology? Where is the future of HIM going? How will the electronic record affect the future? How will Universal Health Care affect health care in general and the HIM profession? Include information about the Health Care Reform, HI-Tech Act, and Stimulus Act. An interview with a professional in Health Information would be great for this presentation. 21

22 Health Information Technology HITT 1301 Data Content & Structure Partner Assignment Student s Names: Telephone #

23

24 Health Information Technology HITT 1301 Health Data Content & Structure Health Information Security/Privacy Week Group Assignment Group I & II: Group III & IV: 24

HEALTH INFORMATION TECHNOLOGY PROGRAM HITT 1301 HEALTH DATA CONTENT AND STRUCTURE/CRN: 77202 Fall 2015/6161/RT

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