Midland College Fall 2008 Syllabus HITT Health Data Content and Structure (4-0-0)

Transcription

1 Midland College Fall 2008 Syllabus HITT Health Data Content and Structure (4-0-0) Course Description Text, References and Supplies This course is an introduction to systems and processes for collecting, maintaining, and disseminating primary and secondary health related information. The course will cover instruction in delivery and organizational structure to include content of health record, documentation requirements, registries, indices, licensing, regulatory agencies, forms, and screens. Textbooks: Essentials of Health Information Management: Principles and Practices with Lab Manual and Blackboard Access Code, Michelle Green & Mary Jo Bowie, Thomson-Delmar Learning, (Referenced in Course Schedule as Green and Green LM ) Health Information Management Technology: An Applied Approach, 2 nd edition, Johns, Merida, Managing Editor. AHIMA, 2007 with Accompanying Student Workbook. (Referenced in Course Schedule as Johns and Johns WB ) Supplies (optional) for Virtual Office: Headset with microphone. To use SKYPE, students need to purchase either a headset with microphone, or a separate microphone to add to your PC (the PC must also have speakers). Headsets can be purchased at most outlets stores that sell electronics (Wal-Mart, Radio Shack, etc). The headsets cost approximately $15.00 to $20.00, and the stand-alone microphones cost approximately $ The LogiTech brand is recommended. Using this option, students will be able to speak to the instructor or other students (or anyone in the world) using SKYPE free of charge through the internet. You will need to go to and download the program. (Most HITT courses have elected to use SKYPE as an additional communication option for students). Course Goals/ Objectives Upon completion of this course, students will be able to: 1. Describe the purpose, organization, structure and functions of a health care facility and medical record department. 2. Describe the job title, correlating duties and certifications of personnel in the medical records department. 3. List and distinguish the accrediting and governing bodies of a medical facility including the State Health Department, Medicare, JCAHO and the hospital requirements to meet those standards. 4. Explain the different purposes and uses of medical records. 5. Describe the components of a medical record and describe the purpose of each (including advanced directives and patients rights) and identify the persons responsible for completion of each components of a record. 6. Trace the flow of a medical record from the time it arrives into a medical records department until it is archived. 7. Perform quantitative analysis. 8. Explain the purpose of reports in specialty and secondary records. 9. Explain medical record filing systems. 10. Collect data on the quality of documentation in the medical record. 11. Trace the location of medical records (i.e. chart tracking systems and MPI=s.) 12. Explain how to retrieve and file medical records and maintain integrity. 13. Describe concurrent medical record review. 14. Describe edit checks to monitor data accuracy. 15. List the sequence of notifying physicians of incomplete records and the result of

2 delinquent records. 16. Describe health care data sets which include UHDDS, HEDIS, and DEEDS. 17. Explain the functions of a tumor registrar, which include accession registry and follow-up requirements. DOMAINS, SUBDOMAINS, AND TASKS: I. Domain: Healthcare Data Management A. Subdomain: Health Data Structure, Content and Standards I.A.1. Collect and maintain health data (such as data elements, data sets and databases). I.A.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. I.A.3. Apply policies and procedures to ensure the accuracy of health data. I.A.4. Contribute to the definitions for and apply clinical vocabularies and terminologies used in the organization s health information systems. I.A.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 I.B.1. Monitor and apply organization-wide health record documentation guidelines. I.B.2. Apply policies and procedures to ensure organizational compliance with regulations and standards. I.B.4. Maintain the accuracy and completeness of the patient record as defined by organizational policy and external regulations and standards. I.B.5. 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 II.A.1. Abstract and maintain data for clinical indices/databases/registries. II.A.5. Use specialized databases to meet specific organization needs such as medical research and disease registries. III. Domain: Health Services Organization and Delivery A. Subdomain: Healthcare Delivery Systems III.A.1. Apply information system policies and procedures required by national health information initiatives on the healthcare delivery system. III.A.2. Apply current laws, accreditation, licensure and certification standards related to health information initiatives from the national, state, local and facility levels. IV. Domain: Information Technology & Systems A. Subdomain: Information and Communication Technologies IV.A.2. Use common software applications such as spreadsheets, databases, word processing, graphics, presentation, and so on in the execution of work processes. IV.A.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. IV.A.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, File Structures IV.B.1. Apply knowledge of data base architecture and design (such as data dictionary, data modeling, data warehousing) to meet departmental needs.

3 C. Subdomain: Data Storage and Retrieval IV.C.1. Use appropriate electronic or imaging technology for data/record storage. IV.C.3. Design and generate reports using appropriate software. IV.C.4. Maintain archival and retrieval systems for patient information stored in multiple formats. V. Domain: Organizational Resources A. Subdomain: Human Resources V.A.7. Prioritize job functions and activities. B. Subdomain: Financial and Physical Resources V.B.1. Make recommendations for items to include in budgets and contracts. V.B.2. Monitor and order supplies needed for work processes. V.B.4. Recommend cost-saving and efficient means of achieving work processes and goals. V.B.5. Contribute to work plans, policies, procedures, and resource requisitions in relation to job functions. Student Contributions and Class Policies ACCESSING AN ONLINE CLASS: Refer to 1.Using Microsoft Mozilla or Netscape 7.0 Navigator, access the Midland College Home page at There have been problems in the past with Internet Explorer and AOL browsers. 2. On the right side of the Midland College home page, click Blackboard. 3. Update your personal profile by clicking on Edit Personal Profile. Verify that your contact information is correct especially your web address and your address and phone number. 4. When the Blackboard page appears, you will need to login to the program. In order to login you must have a login name and password. Your login name will be the first letter of your first name plus the first 3 letters of your last name and the last three numbers of your social security number. For example: the login name for John Smith, social security number , will be jsmi111. Your password will be your social security number using dashes. ( ) 5. After you have logged in, your home page will appear on the screen. On the right side of the page in the box titles My Courses double click on the course you want to view. 6. The course home page will appear. Areas you will want to check frequently are: Announcements, Course Documents, and Assignments. Do not open exams until you are ready to take the test. You can access each exam only one time. 7. In the tools section you can access your grades once they are submitted. Go to Tools then Check Grades. Click on the test or assignment to see comments and feedback. DISCUSSION BOARD: This is the online classroom. Students will respond to discussion questions, post weekly summaries, and communicate with your instructor in the discussion board. Questions about content and assignments should be posted on the discussion board. The posts will be answered daily. Please allow 24 hours for a response. Posts made on the weekend MAY NOT BE answered until Monday. This form of communication is important in online courses. This tool will help you stay connected to other classmates and it will help students to ask those questions just as if you were in an actual classroom setting. Discussion board will also be used as a participation tool, and part of the semester grade is based on participation. When posting a response to the discussion board about a topic, post your original response before reviewing other classmate s postings. Then, read the other postings and respond to at least two other students for full credit for participation.

4 Only when the content of the question is personal in nature should the instructor be ed. When sending , use the Course Name such as QA in your subject line so that the instructor can identify the course being addressed in the followed by the subject matter. Example: To: Instructor s address From: Your address Subject: HITT 1401 Regarding Also be sure to sign your name at the end of the . Remember some addresses give instructors absolutely no clue as to who sent it. ATTENDANCE: Because this is strictly an internet course, attendance will be substituted by participating on the discussion board. You will be required to respond to 2 posts in the discussion board 4 out of 7 days of the week. Answers to the discussion questions, and weekly summaries are counted as a posting. Participation is part of your semester grade. ACADEMIC HONESTY: Students are expected to follow the Academic Honesty policy of Midland College. Using textbooks, assignments and other students, or assistance from others while taking an exam is cheating. Any student cheating will be removed from the class, given an F, and reported to the Registrar s office. Plagiarism will not be tolerated. For more information, review Student Conduct/Misconduct in the MC catalog at pdf. TESTING PHILOSOPHY: Students may politely challenge the instructor on questions they feel were poorly worded. If the instructor concedes the argument, scores will be adjusted for the entire class. Assignments consist of multiple formats including multiple choice, open-ended questions and some true/false. The final examination will be comprehensive over all the material presented during the course. ADA POLICY: Students needing additional time to test due to a documented learning disability, contact Dale Williams, Counselor, at or dwilliams@midland.edu at the beginning of the course to make accommodations. See the current Midland College catalog for more information. COURSE WITHDRAWAL: Students electing to withdraw from course are required to complete a Course Withdraw Form to receive a grade of W at before the last day to withdraw. The last day to withdrawal for this semester: November 13, ONLINE COURSE INFORMATION: PERSONAL INFORMATION: Every semester it is important to update your personal information listed in Blackboard. Check your personal information by going to Personal Information under the MY MC BLACKBOARD tab located directly below the Midland College Logo on your Blackboard screen. Go to Edit Personal Information and update. Once updated, scroll to the bottom of the page and click SUBMIT. Next, click OK. This information is used to contact students. Be sure your address (the one you choose to use for this class) is correct. As stated in the student handbook, Midland College encourages high academic standards, including student responsibility for original work. See the Midland College Student Handbook for more information on the definitions and consequences of cheating, plagiarism, and collusion. Any student found cheating in this course will be removed and a letter grade of F will be posted for the course along with a letter of explanation added in

5 the student file for the offense. COMPUTER REQUIREMENTS: Students should have access to Microsoft Word and Excel for assignment submission. Students taking online courses are responsible to have access to a computer for submission of assignments and postings. For specific computer requirements, see Blackboard System Requirements for Midland College courses at AOL, MSN, and Prodigy browsers will not work with Blackboard. These browsers will lock up or lock you out of assignments and tests. Instead, download Mozilla at or Netscape 7.0. COMPUTER DOWNTIME: This is an online course. Each student is required to have a functioning computer for the entirety of the semester. Having computer problems does not exempt students from completing work by the due date. If the Blackboard system goes down or is unavailable, an announcement will be posted as the due date will be extended. If your system goes down, find another computer to submit your homework/posts before the due date. It is strongly suggested that assignments are to be submitted early to avoid any technical difficulties. SUBMITTING ASSIGNMENTS IN BLACKBOARD: 1. Use a word document format. 2. Save assignment in a rich text file (.rtf). You will find this on your computer under File, Save As, Save Type As (under the name of your document). If you have questions about rtf files, see Course Documents for more information. 3. Each assignment should be submitted through Blackboard under View/ Assignment as an attachment. If there is more than one task due with the assignment such as CH1A (Workbook 1-1, 1-3, and 1-4), all these tasks should be submitted in one word document. DO NOT send three different files. 4. Each assignment should have a header that includes your name, date, course number, and assignment name. Failure to include this content will result in points deducted from your grade. To save: Ch1mct.rtf Ch2jwj.rtf Chapter 1 by Melody Cheryl Thompson (rtf file) Chapter 2 by James W. Johnson (rtf file) Header: Your name Example: Mary Martinez Date Course HITT1401 Assignment Name WB: Individual is discouraged when it involves course assignments and questions about the reading material. These should be posted on the discussion board under the thread Questions to Instructor so that the class may also receive the information since many questions posed to the instructor are commonly asked by more than one individual. In sharing responses with the class, there is equal opportunity (or equitable responses) to receive information from the instructor. If, however, there is a need to send an to the instructor, (due to a personal nature) include in the subject line the course number and the content of the question such as HITT1401 Question on Ch1 assignment. It is also important that you sign your name at the end of the since many s give no indication of the author.

6 Evaluation of Students Assignments 25% Exams 20% Participation/Discussion Boards 10% Group Projects 10% zes 15% Final Exam 20% Total 100% SCANS Information Safety Statement Instructors Information HITT Director Information Health Sciences Division Dean Information The following SCANS skills will be taught and/or reinforced in this course: reading, writing, listening/speaking, thinking skills, and personal qualities. Students will receive annual training in the following: blood and air borne pathogens, electrical safety, back safety, hazardous chemicals, latex allergies, fire and disaster procedures, security and personal safety procedures and safety requirements of clinical facilities. Students must maintain current CPR, immunizations, and health insurance during all clinical courses. Name: Shawnda Meshirer, RHIT, CCS Office Location: A15 Aaron Medical Science Building Address: Office Telephone: or smeshirer Office Hours: Monday 9:00 11:00 a.m. & 1:00-3:00 p.m.; Wednesday & Thursday 9:00-11:00 am Virtual Office Hours on shawnda.him: Monday Evenings 7:00-8:00 p.m. and Tuesday 9:00-11:00 am Program Director: Melinda Teel, BSHIM, RHIT, CCS Office Location: A33 Aaron Medical Science Building Office Telephone: Address: mteel@midland.edu Division Dean: Dr. Becky Hammack Health Sciences Division Secretary and Clerk: Kay Floyd and Alma Guyse Division Office Location and Telephone: 209 Davidson Health Sciences Building Office Telephone: Students are encouraged to contact the instructor at any time; however, making an appointment will guarantee the instructor s availability at a specific time. Course Schedule The course schedule has due dates and each student is expected to submit assignments on or before midnight Central Standard Time of the due date. There is no formal provision for make-up work or extra credit in this course. Work submitted after the deadline will not be accepted. Once the assignment date closes, assignments cannot be submitted. A zero will be placed in the grade book for late assignments. Please do not wait until the last minute to attempt assignments. Computers and computer networks have a bad habit of crashing at the very time you need them the most.

7 HITT 1401 Health Data Content Course ing, Assignment and Test Schedule: (Due dates and assignments may change at the discretion of the instructor. Any changes will be posted on Blackboard in Announcements.) Due Date Task Assignment/Exams 8/28 & Pre-Test and Orientation DB: Introduce Yourself Johns: Chapters 1 and 2 Intro/Functions of the Health Record Section #1 9/2 Johns WB: Ch 1 & 2 Review zes, Ch 2 Real World Case #1 Discussion Questions, Ch 2 Application Exercise #3. DB: Speech Recognition/Maintenance of Health Records: AE 5 or 6 9/9 Johns: Ch 13 Healthcare Delivery Systems Johns WB: Ch 13 Real World Case Discussion Questions and Review DB: Governmental Role in Healthcare: AE #1 9/16 Johns: Ch 3: Content and Structure of Health Record Section #2 9/23 Johns WB: Ch 3 Real World Case Discussion Questions and Review DB: AHA Organization 9/18 TEST Section 1A Exam Green: Chapters 1 and 2: History/Ownership/Structure/Licensure, Regulation, and Accreditation Green LM: : Lab Assignment 2-4 Ethics 1-6 on discussion board. Submit 7 12 and Lab Assignment 2-5 Journal Abstracts for AHIMA. Review Green Chapters 1 & 2 DB: Reply to 2 questions on ETHICS as posted and respond to at least 2 other student s responses. 9/30 10/7 10/9 TEST Section 2B Exam Green Ch 5: Patient Record: Inpatient/Outpatient/Physician Green LM: : Lab Assignment 5-2 Quantitative and Qualitative Analysis of Patient Records and Lab Assignment 5-3 Forms Design DB: Forms Design and Data (page 186 Green) Green: Ch 4: Patient Record: Hospital/Physician Office/Alternative Care Setting Green LM: Review all lab assignments for Chapter 4. : Lab Assignment 4-2 Provider Documentation Guidelines and Lab Assignment 4-4 Medicare Conditions of Participation Review Green Chapters 4 & 5 DB: Medicare and You

8 Page 19 HITT 1401 Health Data Content Course ing, Assignment and Test Schedule: (Due dates and assignments may change at the discretion of the instructor. Any changes will be posted on Blackboard in Announcements.) Johns: Ch 4 Electronic Health Records Section #3 10/14 Johns WB: Ch 4 Real World Case Discussion Questions and Review DB: AE - Decision support systems, EHR Johns: Ch 5 Healthcare Data Sets 10/21 Johns WB: Ch 5 Real World Case Discussion Questions and Review and Application Exercise #4 (ORYX and HEDIS) and Application Exercise #5 (Health Informatics Standards) DB: NCHIT Johns: Ch 6 Clinical Vocabularies and Classification Systems 10/28 Johns WB : Ch 6 Real World Case Discussion Questions and Review DB: Coding Functions/Software Johns: Ch 8 Health Information Technology Functions Johns WB: Ch 8 Real World Case Discussion Questions and Review 11/4 Group Project: #1: Vendors of Filing Systems (Johns WB page 40) DB: No discussion board this week. Work on Group Project. 11/6 TEST Section 3C Exam Green: Ch 6 Numbering & Filing Systems and Record Storage and Circulation Green LM: : Lab Assignment 6-1 Part I and II Numeric and Terminal-Digit Filing Systems Section #4 Lab Assignment 6-2 Calculating Record Storage Needs 11/11 Lab Assignment 6-3 Guiding Terminal-Digit Files Review Green Chapter 6 DB: EHR Technology 11/16 Cancer Registry Tutorial See assignment for more details. 11/18 Green: Ch 7 Indexes, Registries, and Health Data Collection Green LM: : Lab Assignment 7-1 Case Abstracting Lab Assignment 7-2 Master Patient Index Data Entry Lab Assignment 7-3 Disease, Procedure and Physician Indexes Review Green Chapter 7 DB: Data Sets and Organizations (extra credit) TEST Section 4D Exam Johns: Ch 9 Secondary Data Sources Section #5 11/24 12/2 Johns WB: Ch 9 Real World Case Discussion Questions and Review DB: Research and Registries (Johns WB Page 46) Green: Ch 8 Legal Aspects of Health Information Green: Ch 9 Coding and Reimbursement Green LM: Group Project #2: Lab Assignment 8-1 Notice of Privacy Practices Lab Assignment 8-2 Release of Patient Information Lab Assignment 8-3 Release of Information Correspondence Log Lab Assignment 8-4 Telephone Calls for ROI Processing Lab Assignment 9-1 Hospital Financial Reports Review Green Chapters 8 and 9 DB: Reflection 12/3 Student Evaluation Survey and Post-Test 12/8 TEST Final Examination