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 builds the foundation for managing medical records.  This course will emphasize the various patient record formats and required content, the maintenance of the patient record, and the health data provided in an electronic health record. Students will be introduced to data quality and how the data is used for management decision making and strategic planning.

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 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 through sample patient records, 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	Demonstrate through the application of policies and procedures to ensure accuracy and integrity of health data, both internal and external to the health system.
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:

• Demonstrate understanding of the various types of patient records;
• Verify the documentation in the health record is timely, accurate, and complete;
• Differentiate the roles and responsibiliites of various providers and disciplines, to support the documentation requirements, throughout the continuum of care;
• Identify a complete health record according to organizational policies, external regulations, and standards;
• Utilize basic descriptive, institutional, and healthcare statistics;
• Identify potential abuse or fradulent trends through data analysis;
• 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
• 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
• Healthcare facility ownership
• Healthcare facility organizational structure
• 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. Collecting Healthcare Data
• Basic concepts
• Administrative data elements
• Master Patient Index (MPI)
• Key data categories of a health record
• Describing data
• Organization of data elements in a health record
• Data sets
• Data quality
5. Electronic Health Records
• Evolution of electronic health records
• Electronic health record systems
• Regional health information organization
• Components of electronic health record systems used in healthcare
6. Content of the Patient Record
• General documentation issues
• Clinical flow of data
• Clinical data
• Physician
• Nurses
• Laboratory
• Radiolology
• Special records
• Discharge data set
7. Health Information Processing
• Postdischarge processing
• Electronic health record (EHR) management
• Scanning and indexing
• Record analysis
• Abstracting
• Storage and retention
• Release of information
• Cut, copy and paste(cloning) in EHR
8. Code Sets
• Purpose of code sets
• ICD-10-CM
• ICD-10-PCS
• HCPCS/CPT
• Special classification of code sets
• SNOMED-CT
• DSM-IV, DSM-IV-TR, and DSM-5
• National drug codes
• Uses for coded clinical data
9. Managing Health Data
• Uses of health information
• Monitoring the quality of health information
• Record storage issues
• Security of health information
• Information systems down time procedures
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
• Release of information and medical records preperation
11. HIM Department Management
• Organization and interdepartmental relationships
• Workflow and productivity
• Departemtn policies and procedures
• Personnel
• Performance standards
• Evaluating productivity
12. Future of Information and Informatics