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

4. Course Description:

This course will introduce students to the content of a health record, the various patient record formats, documentation requirements and data governance. Using hands-on application, the students will learn both clinical and health information management functions and procedures to analyze records, ensure compliance, and data accuracy. The course covers electronic health record use in acute care, outpatient, and long-term care settings.

5. Placement Tests Required:

Accuplacer (specify test):

No placement tests required

Score:

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

2. Transfer - regional institutions with which this course has a written articulation agreement:

College of St. Scholastica, Articulation agreement signed Summer 2020 (HIM 2110)

MSU - Moorhead, Articulation agreement signed Spring 2019 (MSU-M Electives)

III. Course Purpose

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

Healthcare Administrative Specialist, AAS
Healthcare Administrative Specialist, 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 through sample, the ability to ensure the documentation supports the diagnosis and reflects the patient's progress, clinical findings, and discharge status.
Apply abstract ideas to concrete situations	Explain the requirements of the Centers for Medicare & Medicaid (CMS) for the clinical decision support rule as part of meaningful use core measures.
Apply ethical principles in decision-making	Demonstrate the ability to analyze policies and procedures to ensure compliance with regulations and standards using scenario based cases.

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

• Describe the requirements and standards for the health record;
• Describe the primary and secondary uses of an electronic health record system; 
• Differentiate the roles and responsibilities of various providers and disciplines, to support the documentation requirements, throughout the continuum of care;
• Explain the purpose of secure messaging, document management, laboratory integration, and e-prescribing features of an EHR; 
• Demonstrate clinical decision support activities in electronic health record software; 
• Identify a complete health record according to organizational policies, external regulations, and standards;
• Utilize data for facility-wide outcomes reporting for quality management and performance improvement;
• Explain usability and accessibility of health information by patients, including current trends and future challenges; and
• Explain the clinical documentation cycle and provide examples of its use in inpatient, outpatient, and long-term care settings. 

V. Topical Outline

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

1. Lecture Sessions

1. Healthcare Delivery Systems
• Healthcare facility ownership
• Healthcare facility organizational structure
• Licensure, regulation, and accreditation
2. Health Information Management Professionals
   • Careers
   • Professional practice experience
   • Professional associations
   • Ethical standards of practice
3. Healthcare 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 healthcare
4. Patient Record
• Record
• Ownership
• Hospital Inpatient
• Hospital Outpatient
• Physician Office
• Alternate Care Settings
• Provider Responsibilities
• Authentication
• Entries
• Abbreviations
• Timeliness
• Amendments
• Development
• Inpatient Record: Admission to Discharge
• Date Order
• Outpatient Record: Handling Repeat Visits
• Physician Office Record: Continuity of Care
• Patient Record Formats
• Patient Record Completion
5. Electronic Health Records (EHR)
• History and purpose
• Electronic health record (EHR) vs. Electronic medical record (EMR)
• Federal regulations
• Benefits and barriers
• Legal issues
• Privacy and security
• Health record data
• Administrative
• Clinical
• Legal
• Financial
• Format
• Source-oriented record
• Integrated health record
• Problem-oriented record
• Standards
• Standard development organizations
• Vocabulary standards
• Messaging standards
• Code Sets
• Purpose of code sets
• ICD-10-CM
• ICD-10-PCS
• HCPCS Level II
• CPT
• Components of electronic health record systems used in healthcare
• Interoperability
• Impact on health information management
• Health Information Exchange (HIE)
• Health Information Systems 
6. Clinical Documentation
• Documentation Cycle
• Documentation Issues
• Inpatient
• History and physical exam (H&P)
• Chart templates
• Care plan
• Emergency Record
• Discharge Summary
• Consultation Report
• Anesthesia Record
• Operative Record
• Pathology Report
• Nursing documentation
• Nursing Staff
• Certified nursing assistant (CNA)
• Licensed practice nurse (LPN)
• Registered nurse (RN)
• Assessments
• Nursing admission assessment
• Infection control assessment
• Fall risk assessment
• Skin assessment
• Pain assessment
• Pressure injury risk assessment
• Wound assessment
• Daily charting
• Clinical documentation cycle
• Nursing plan of care
• Daily nurse notes
• Electronic Documentation of Medications and Treatments
• Medication administration record
• Bar-coded medication administration
• Treatment administration record
• Intake and output flowsheets
• Vital signs flowsheets
• Nursing discharge documentation
• Progress reports
• e-Prescription
• Orders
• Medication administration record
• Flowsheets
• Therapy documentation
• Post Anesthesia Care Unit (PACU)
• Ancillary Reports
• Special Reports
• Autopsy Reports
• Outpatient
• History and physical exam (H&P)
• Chart templates
• e-Prescription
• Superbill
• Skilled Nursing and Rehabilitation
7. Health Information Processing
• Post discharge processing
• Electronic health record (EHR) management
• Scanning and indexing
• Document imaging
• Privacy notice
• Financial agreements
• Consent forms
• Advance directives
• Record analysis
• Abstracting
• Storage and retention
• Release of information
• Cut, copy and paste(cloning) in EHR
8. Managing Health Data
• Data sources
• Data integrity
• Data Sets
• Uniform Hospital Discharge Data Set
• Uniform Ambulatory Care Data Set
• Minimum Data Set
• Outcomes and Assessment Information Set
• Data elements for Emergency Department Systems
• Databases
• Data registries
• Cancer registries
• Clinical trials
• Trauma registries
• Immunization registries
• Information Governance
• Uses of health information
• Monitoring the quality of health information
• Information systems down time procedures
9. Clinical Decision Support Systems (CDSS) and Quality Improvement
• Clinical decision support
• Common uses
• Benefits and drawbacks
• Role of EHRs in quality improvement
• Clinical documentation improvement processes
10. eHealth
• Telehealth/Telemedicine
• Remote patient monitoring
• Personal health records (PHR)
• Content
• Types
11. HIM Department Management
• Organization and interdepartmental relationships
• Workflow and productivity
• Department policies and procedures
• Personnel
• Performance standards
• Evaluating productivity