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 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.   The course will provide students with hands-on experience using a combination practice management and electronic health record system to manage the medical record content and to use the database to create reports to be used in administrative decision making.

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

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

College of St. Scholastica, June 2014 (CSS course equivalent HIM 2110 Concepts & Principles of HIM)

III. Course Purpose

1. Program-Applicable Courses – This course is required for the following program(s):

Healthcare Administrative Specialist, AAS
Healthcare Administrative Specialist, Diploma
Healthcare Administrative Specialist, Certificate
Healthcare Technology, AAS

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; and
• 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.  Healthcare Delivery Systems
• History of medicine and healthcare delivery
• Continuum of care
• Healthcare facility ownership
• Healthcare facility organizational structure
• Cancer registr
• Licensure, regulation, and accreditation
2. Health Information Management Professionals
   • Careers
   • Professional practice experience
   • Professional associations
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. 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 healthcare
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. Management of Information and Communication
• Internal communications
• Importing documents into the EHR
• Master files and templates
• Customization
• Software reminders
8. Registers
   • Case abstracting
9. Health Data Collection
• Administrative data elements
• administrative uses of data
• Master Patient Index (MPI)
• Registration and scheduling
10. Privacy, Security, Confidentiality and Legal Issues
• Evaluating an EHR system for HIPAA compliance
• Role of certification of EHR implemenation
• Handling sensitive or restricted-access record
• Applying security measures
• Compliance plans
• Safeguarding the system and contingency planning.
11. Future of Information and Informatics