Portland Community College | Portland, Oregon

Course Number:
HIM 141
Course Title:
Health Record Content in Non-Acute Care Settings
Credit Hours:
3
Lecture Hours:
30
Lecture/Lab Hours:
0
Lab Hours:
0
Special Fee:
 

Course Description

Addresses the concepts of health information management including components of the content, use, and structure of non-acute health care data. Audit available.

Intended Outcomes for the course

Upon completion of this course students should be able to:

  1. Describe and validate the documentation in the health record to ensure it supports the diagnosis and reflects the patient's progress, clinical findings, and discharge status.
  2. Validate that outpatient and alternative care setting documentation in the health record is timely, complete and accurate.
  3. Describe a complete outpatient and alternative care setting health record according to organizational policies, external regulations and standards.

Outcome Assessment Strategies

Students will demonstrate these learning outcomes by these tasks conducted individually and in cooperation with outer students:

  1. Answer theoretical and application questions on information covered in the lecture, graded assignments and reading assignments.
  2. Locate data requirements in federal, state, and accrediting bodies documentation.

Course Content (Themes, Concepts, Issues and Skills)

To complete the outcomes in this course students must have skills in:

  • Federal and state regulations for health records
  • Joint Commission documentation standards
  • Accrediting agencies documentation standards
  • Medical terminology