COURSE DESCRIPTION
Supervises student practice in health information activities conducted in a variety of clinical settings. Clinical 6 hours per week.
GENERAL COURSE PURPOSE
This course is designed to prepare the Health Information Technology student to perform all functions commonly allocated to health record services. Students will practice skills in various settings under the supervision of a clinical practice supervisor. The purposes of the clinical experiences provided in the course are to expose the student to the work place setting and to permit the student to demonstrate entry-level competencies in various health record services settings.
ENTRY LEVEL REQUIREMENTS
Students must be able to read and write at a college level, and have a willingness to learn.
COURSE OBJECTIVES
Upon successful completion of the course, the student will demonstrate entry-level competencies in the following areas:
B. Inputting data into computerized databases
C. Following existing procedures for the manual or automated issuing of patient numbers
D. Answering telephone requests for patient numbers
E. Performing quality checks on the database
F. Filing complete records into permanent files
G. Filing incomplete records and loose papers
H. Completing request slips
I. Performing quality checks in the files
J. Searching for misfiles
K. Pulling records from file on request
L. Filing and reproducing microfilm
M. Preparing records for microfilm
N. Scanning documents for optical disk storage
O. Initial or second analysis of incomplete records
P. Reading suspension policies and procedures
Q. Notifying physicians of delinquent records
R. Determining and tabulating incomplete and delinquent records
S. Assisting physicians and other health care providers with timely record completion
T. Identifying potential "risk" cases
U. Maintaining a database for control of incomplete records
V. Ensuring confidentiality
of health information is maintained
W. Maintaining security of computerized information
X. Mailing information
Y. Accepting valid subpoenas according to procedure
Z. Preparing records for court proceedings
AA. Coding and classifying inpatient and ambulatory care records using ICD-9-CM and CPT using existing procedures for coding diagnoses, symptoms, procedures and external causes of injury.
BB. Applying definitions and guidelines to determine the principal diagnosis for DRG assignment
CC. Performing DRG, AP-DRG, and APC assignment utilizing an automated grouper
DD. Discussing case mix management reports
EE. Discussing the impact of DRGs, AP-DRGs, and APCs on health information services, OIG fraud and abuse investigation impact, and compliance program operation
FF. Accepting patients for admission and doing pre-admission preparations
GG. Identifying room or surgical suite assignment
HH. Performing admission functions
II. Preparing patient bills for insurance company or managed care submission
JJ. Tracking outstanding unpaid bills
KK. Tracking payments received
LL. Reviewing existing policies for departmental functions and following existing procedures of departmental functions
MM. Identifying and accessioning cases
NN. Assigning ICD-O codes to diagnoses
OO. Entering data into automated or manual databases
PP. Computing statistics and preparing reports
QQ. Completing follow-up activities
RR. Attending Tumor Board or Cancer Committee meeting
SS. Preparing for Medical Staff committee which performs information management, performance improvement, or other function required by JCAHO standards
TT. Reading all policies and procedures relating to the selected committee
UU. Preparing of committee agenda
VV. Sending of meeting notices to committee members
WW. Preparing of information and reports for committee consideration
XX. Writing and typing committee meeting minutes
YY. Reviewing patient health records, internal databases and external reference databases to identify actual practice data
ZZ. Identifying pattern variations and correlating actual practice to pre-identified criterion or guideline
AB. Displaying actual practice data and identifying key information for variation analysis and practice improvement
AC. Assisting in preparing for committee or team meetings or external survey inspections
AD. Performing pre-admission or admission certification
AE. Performing continued stay review
AF. Participating in discharge planning
AG. Participating in clinical pathway development or monitoring
AH. Assisting in report preparation
B. Record Completion Management
C. Correspondence Management
D. Coding/Classification/Case Mix Management
E. Admission Office
F. Business Office
G. Cancer Registry
H. Committee Preparation/Attendance
I. Quality/Performance Management
J. Utilization Management/Clinical Pathways