HM 112 Health Record Content

Lecture Hours: 3
Lab Hours: 3
Credits: 4

Provides entry-level skills for Health Information Management. Offers basic knowledge of health information systems and the skills necessary for medical and hospital administrative functions. Includes Electronic Health Record (EHR) systems, the health information field, the content of a health record, health record processing of medical reports, documentation guidelines, and legal/ethical aspects of the health record. Includes introduction to patient registration.

Prerequisite: Enrolled in HIM healthcare Coding Certificate
Student Learning Outcomes:

Identify the types of health care facilities.
Differentiate the roles and responsibilities of various providers and disciplines to support documentation requirements throughout the continuum of care.
Explain the functions of the departments involved in the health information system.
Conduct analysis to ensure that documentation in the health record supports the diagnosis and reflects the patient’s progress, clinical findings, and discharge status.
Apply policies and procedures to ensure the accuracy of health data.
Verify timeliness, completeness, accuracy, and appropriateness of data and data sources for patient care, management, billing reports, registries, and/or databases.
Identify a complete health record according to organizational policies, external regulations, and standards.
Apply policies and procedures of access and disclosure of protected health information.
Explore the functions of practice management.

Content Outline

Health Record Content
- Purposes, uses and responsibilities
- Standards/agencies
- Development of the medical record
- Basic content of hospital and physician’s office health record
- Data entries as essential record components
Numbering and Filing Health Records
- Number assignment
- Filing methods and procedures
- Retention/retrieval systems
Indexes, Registers and Files
- Patient index
- Disease and operation index
- Physician’s index
- Registers
- Retention
Legal/Ethical Aspects
- Patient rights (including patient valuables)
- Confidentiality of the health information
- Monitoring confidentiality
- Ownership of information
- Release of information
- Consents and authorizations
- Vital statistics
- Introduction to HIPAA rules and regulations
Computer systems and HIM
- Computer technology – Electronic Health Record
- Computer technology and a HIM department
- Basic patient registration
Evaluation of Patient Care through Documented Health Information
- Introduction to documentation guidelines
- Roles and documentation responsibilities of various providers Components of chart analysis