HITT 2207 - Professional Practice Experience

Credit Hours: 3.00

Objectives:

1. Collect and maintain health data (such as data elements, data sets, and databases).
2. Conduct analysis to ensure documentation in the health record supports the diagnosis and reflects the patients progress, clinical findings, and discharge status.
3. Apply policies and procedures to ensure the accuracy of health data.
4. Contribute to the definitions for and apply clinical vocabularies and terminologies used in the organization’s health information systems.
5. Verify timeliness, completeness, accuracy, and appropriateness of data and data sources for patient care, management, billing reports, registries, and/or databases.
6. Monitor and apply organization‐wide health record documentation guidelines.
7. Apply policies and procedures to ensure organizational compliance with regulations and standards.
8. Report compliance findings according to organizational policy.

Outcome 2: Upon completion of this course, students will be able to apply healthcare information requirements and standards.

Objectives:

1. Maintain the accuracy and completeness of the patient record as defined by organizational policy and external regulations and standards.
2. Assist in preparing the organization for accreditation, licensing, and/or certification surveys.
3. Apply information system policies and procedures required by national health information initiatives on the healthcare delivery system.
4. Apply current laws, accreditation, licensure, and certification standards related to health information initiatives from the national, state, local, and facility levels.
5. Apply policies and procedures to comply with the changing regulations among various payment systems for healthcare services such as Medicare, Medicaid, managed care, and so forth.
6. Participate in the implementation of legal and regulatory requirements related to the health information infrastructure.

Outcome 3: Upon completion of this course, students will be able to apply clinical classification systems.

Objectives:

1. Use and maintain electronic applications and work processes to support clinical classification and coding.
2. Apply diagnosis/procedure codes using ICD‐10‐CM and ICD‐10‐PCS.
3. Apply procedure codes using CPT/HCPCS.
4. Ensure accuracy of diagnostic/procedural groupings such as DRG, APC, and so on.
5. Adhere to current regulations and established guidelines in code assignment.
6. Validate coding accuracy using clinical information found in the health record.
7. Resolve discrepancies between coded data and supporting documentation.

Outcome 4: Upon completion of this course, students will be able to distinguish reimbursement procedures.

Objectives:

1. Apply policies and procedures for the use of clinical data required in reimbursement and prospective payment systems (PPS) in healthcare delivery.
2. Produce accurate billing through coding, charge master, claims management, and bill reconciliation processes.
3. Apply established guidelines to comply with reimbursement and reporting requirements such as the National Correct Coding Initiative.

Outcome 5: Upon completion of this course, students will be able to interpret policies governing healthcare statistics and research.

Objectives:

1. Compute and interpret healthcare statistics.
2. Apply Institutional Review Board (IRB) processes and policies.
3. Use specialized databases to meet specific organization needs such as medical research and disease registries.

Outcome 6: Upon completion of this course, students will be able to identify quality management and performance improvement processes.

Objectives:

1. Collect, organize, and present data for quality management, utilization management, risk management, and other related studies.
2. Abstract and report data for facility‐wide quality management and performance improvement programs.
3. Analyze clinical data to identify trends that demonstrate quality, safety, and effectiveness of healthcare.
4. Compile patient data and perform data quality reviews to validate code assignment and compliance with reporting requirements such as outpatient prospective payment systems.
5. Abstract and maintain data for clinical indices/databases/registries.
6. Summarize data compiled from audit trail and data quality monitoring programs.

Outcome 7: Upon completion of this course, students will be able to differentiate the healthcare delivery systems.

Objectives:

1. Differentiate the roles of various providers and disciplines throughout the continuum of healthcare and respond to their information needs.

Outcome 8: Upon completion of this course, students will be able to interpret healthcare privacy, confidentiality, legal and ethical issues.

Objectives:

1. Apply policies and procedures for access and disclosure of personal health information.
2. Release patient‐specific data to authorized users.
3. Maintain user access logs/systems to track access to and disclosure of identifiable patient data.
4. Conduct privacy and confidentiality training programs.
5. Investigate and recommend solutions to privacy issues/problems.
6. Apply and promote ethical standards of practice.
7. Apply confidentiality and security measures to protect electronic health information.

Outcome 9: Upon completion of this course, students will be able to utilize information and communication technologies.

Objectives:

1. Use technology, including hardware and software, to ensure data collection, storage, analysis, and reporting of information.
2. Use common software applications such as spreadsheets, databases, word processing, graphics, presentation, e‐mail, and so on in the execution of work processes.
3. Use specialized software in the completion of HIM processes such as record tracking, release of information, coding, grouping, registries, billing, quality improvement, and imaging.
4. Apply policies and procedures to the use of networks, including intranet and Internet applications to facilitate the electronic health record (EHR), personal health record (PHR), public health, and other administrative applications.
5. Apply knowledge of data base architecture and design (such as data dictionary, data modeling, data warehousing) to meet departmental needs.

Outcome 10: Upon completion of this course, students will be able to utilize data storage and retrieval systems.

Objectives:

1. Use appropriate electronic or imaging technology for data/record storage.
2. Query and generate reports to facilitate information retrieval.
3. Design and generate reports using appropriate software.
4. Maintain archival and retrieval systems for patient information stored in multiple formats.
5. Coordinate, use, and maintain systems for document imaging and storage.

Outcome 11: Upon completion of this course, students will be able to apply data security and healthcare information systems.

Objectives:

1. Protect data integrity and validity using software or hardware technology.
2. Apply departmental and organizational data and information system security policies.
3. Contribute to the design and implementation of risk management, contingency planning, and data recovery procedures.
4. Participate in the planning, design, selection, implementation, integration, testing, evaluation, and support for organization‐wide information systems.

Outcome 12: Upon completion of this course, students will be able to explain various organizational resource skills.

Objectives:

1. Apply the fundamentals of team leadership.
2. Organize and contribute to work teams and committees.
3. Conduct new staff orientation and training programs.
4. Conduct continuing education programs.
5. Monitor staffing levels and productivity standards for health information functions, and provide feedback to management and staff regarding performance.
6. Communicate benchmark staff performance data.
7. Prioritize job functions and activities.
8. Use quality improvement tools and techniques to monitor, report, and improve processes.
9. Make recommendations for items to include in budgets and contracts.
10. Monitor and order supplies needed for work processes.
11. Monitor coding and revenue cycle processes.
12. Recommend cost‐saving and efficient means of achieving work processes and goals.
13. Contribute to work plans, policies, procedures, and resource requisitions in relation to job functions.
14. Use the principles of ergonomics and human factors in work process design.

1. Release of Information
2. Retention Regulations
3. Healthcare information requirements and standards
4. Data Security
5. Healthcare security and privacy
6. CPT coding
7. ICD-10-CM Coding
8. ICD-10-PCS Coding