HIT 125 - Health Data Structure, Content & Standards

5 Credits

Students will explore the structure and format of health records across various settings as well as storage systems used in health information management (HIM). Students will gain an insight into the numerous databases, registries, and indices used in HIM. Federal and state regulations involving HIM will also be addressed.

Program Admission Required Yes Admitted Program HIT
Fees

Quarters Typically Offered

Spring Online

Designed to Serve Students in Professional Coding Certificate program.
Active Date 2016-02-18

Grading Basis Decimal Grade
Class Limit 20
Contact Hours: Lecture 55 Lab 0 Field Studies 0 Clinical 0 Independent Studies 0
Total Contact Hours 55
Degree Distributions:
ProfTech Course Yes
Restricted Elective Yes
Course Outline
1. The Role of Health Information Management

2. The Medical Record

3. Health Record Documentation and Clinical Settings

4. Accreditation and Regulations

5. Intro to Health Data Sets

6. Medical Record Functions and Secondary Data Sources

Student Learning Outcomes
Identify documentation in the health record to ensure it supports the diagnosis and reflects the patient’s prognosis, clinical findings, and discharge status.

Identify legal documents in the health record (consent for treatment, patient rights, DNR, advance directives).

Identify requirements for timely, complete, and accurate documentation.

Recognize a complete health record according to organizational policies, external regulations, and standards.

Discuss the roles and responsibilities of various providers and disciplines, to support documentation requirements, throughout the continuum of care (healthcare providers, administrative).

Identify software used for Personal Health Records.

Explain usability and accessibility of health information by patients, including current trends and future challenges with PHRs.

Define accreditation, licensure, and/or certification.

Identify ethical standards of practice (professional and practice-related ethical issues - AHIMA Code of Ethics).

Identify the consequences of a breach of healthcare ethics.