I. General Information

1. Course Title:
Medical Records Management

2. Course Prefix & Number:
HINS 1165

3. Course Credits and Contact Hours:

Credits: 3

Lecture Hours: 3

Lab Hours: 0

4. Course Description:

This course is an introduction to procedures for managing medical records.  The emphasis of this course is patient record formats and the contents of an inpatient, outpatient and physician office medical record.   This course also includes manual and electronic storage and retrieval; with attention to HIPAA laws and legislation, recover audit contractor programs (RAC) and release of protected health information.

5. Placement Tests Required:

6. Prerequisite Courses:

There are no prerequisites for this course.

9. Co-requisite Courses:

There are no corequisites for this course.

II. Transfer and Articulation

1. Course Equivalency - similar course from other regional institutions:

Rochester CTC, HIMC 1840 Intro to Health Records, 4 credits
Mn State, ADMM 2262 Auditing the Medical Record- Surgical & Ancillary Services, 3 credits
Mn State, ADMM 2264 Auditing the Medical Record - Facility, 2 credits

III. Course Purpose

1. Program-Applicable Courses – This course fulfills a requirement for the following program(s):

Health Informatics Specialist, AAS
Health Informatics Coordinator, Diploma

IV. Learning Outcomes

1. College-Wide Outcomes

College-Wide Outcomes/Competencies	Students will be able to:
Analyze and follow a sequence of operations	Demonstrate the requirements for a complete medical record by auditing information in sample patient records.
Apply abstract ideas to concrete situations	Differentiate and provide examples of administrative and clinical data.
Apply ethical principles in decision-making	Demonstrate the ability to appropriately release protected health information (PHI)

2. Course Specific Outcomes - Students will be able to achieve the following measurable goals upon completion of the course:

• List and define hospital categories and identify types of hospital patients
• Differentiate among freestanding, hospital-based, and hospital-owned ambulatory care settings
• List provider documentation responsibilities
• Demonstrate understanding of the various types of patient records
• Demonstrate the correct method for correcting documentation
• Explain the patient record completion and who is responsible for the completing each section.
• Provide examples of computerized patient records, electronic patient records and electronic health records
• Explain general documentation issues that impact all patient records.
• Demonstrate through samples the ability to comply with HIPAA privacy and security provisions when releasing protected health information.

V. Topical Outline

Listed below are major areas of content typically covered in this course.

1. Lecture Sessions

1. Health Care Delivery Systems
   • History of medicine and health care delivery
   • Continuum of care
   • Health care facility ownership
   • Health care facility organizational structure
   • Cancer registry
   • Licensure, regulation and accreditation
2. Health Information Management Professionals
   • Careers
   • Professional practice experience
   • Professional associations
3. Health Care Setting
   • Acute care facilities
   • Ambulatory and outpatient care
   • Behavioral health care facilities
   • Home care and hospice
   • Long-term care
   • Managed care
   • Federal, state and local health care
4. The Patient Record:  Hospital, Physician Office, and Alternate Care Settings
   • Definition and purpose of the patient record
   • Provider documentation responsibilities
   • Development of the patient record
   • Patient record format
   • Archived records
   • Patient record completion responsibilities
5. Electronic Health Records
   • Evolution of electronic health records
   • Electronic health record systems
   • Regional health information organizations
   • Components of electronic health record systems used in health care
6. Content of the Patient Record:  Inpatient, Outpatient and Physician Office
   • General documentation issues
   • Hospital inpatient record – administrative data
   • Hospital inpatient record – clinical data
   • Opps major and minor procedures
   • Hospital outpatient record
   • Physician office record
   • Forms control and design
7. Indexes
8. Registers
   • Case abstracting
9. Health Data Collection
10. Legal Aspects of Health Information Management
    • Legal and regulatory terms
    • Maintain the patient record in the normal course of business
    • Confidentiality of information
    • HIPAA privacy and security provisions
    • Legislation that impacts health information management
    • Release of protected health information
11. Introduction to Coding and Reimbursement
    • Nomenclatures and classification systems
    • Third-party payers
    • Health care reimbursement systems