Course Description

This course will address healthcare delivery in the United States, clinical documentation, functions of the health record, primary and secondary data sources, health record documentation best practices, accreditation and regulations, and the continuum of care. Part 1 of 2.

Credits/Modes of Instruction

Credits:  3

Lecture presented as MS PowerPoint Presentations
Assignments/Projects (graded written assignments/project submission)
Textbook activities
Laboratory Exercises utilizing software accessible remotely
Canvas Learning System
Videos

Prerequisites

None. This course is open to all medical, dental, public health and health related professions students. Students must have access to the internet.

Course Goals and Outcomes:

Goals

This course introduces students to traditional hospital-based HIM practice as well as expanded practice in multiple health care settings, including but not limited to long-term care, rehabilitation, home care, respite care and hospice care. The evolution of health records from paper to electronic will be explored.

Upon completion of this course, the student will be able to:
Identify the factors that determine the content of the health record
Identify the organizations and standards for the content of the health record
Differentiate between quantitative and qualitative analysis
Articulate the impact of regulatory change on the healthcare delivery system
Describe the importance of a professional code of ethics and specifically the HIM Code of Ethics