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.

Credits/Modes of Instruction

Credits:  3

Lecture presented as MS PowerPoint Presentations
Assignments/Projects
Textbook activities
Canvas Learning System – web-based instruction
EHRGo virtual lab system – web-based lab activities
Videos

Prerequisites

This course is open to all students who have successfully completed BINF 3126.

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. The course focuses on the organizational and management of health record.

Upon completion of this course, the student will be able to:

Evaluate data structure and data dictionaries in an electronic health record.
Identify classification systems, clinical vocabularies and terminologies.
Examine strategies for managing health record flow, access, retention and integrity.
Recommend health record content requirements across the health system.
Determine compliance of health records with standards and requirements from federal, state, and other regulatory and accrediting agencies.