- Course Number:
- HIM 120
- Course Title:
- Health Record Content in Acute Care Settings Lab
- Credit Hours:
- Lecture Hours:
- Lecture/Lab Hours:
- Lab Hours:
- Special Fee:
Course DescriptionProvides an opportunity to practice auditing health records and recognize key elements of health record documents. Corequisites: HIM 110.
Intended Outcomes for the course
Upon completion of the course students should be able to:
- Utilize software in the completion of health record analysis tasks.
- Identify the documentation in the health record to ensure it supports the diagnosis and reflects the patient's progress.
- Validate that the acute care documentation in the health record is timely, complete, and accurate.
- Define health data elements and data set terminology
- Collect the Uniform Hospital Discharge Data Set (UHDDS) sources.
Outcome Assessment Strategies
Students will demonstrate these learning outcomes by these tasks conducted individually and in cooperation with other students by:
- Successful completion of assigned modules as outlined on lab schedule.
Course Content (Themes, Concepts, Issues and Skills)
- Explain current formats for data and information collection and the various ways in which data and information are collected.
- Understand data access and retention of paper-based, image-based and electronic information.
- Transmitted information electronically via phone, fax and e-mail.
- Maintain filing and retrieval systems for paper-based patient records.
- Audit the master patient index for errors.
- Identify the various professionals working in health care facilities.