CHATTANOOGA STATE COMMUNITY COLLEGE
CHATTANOOGA, TENNESSEE
NURSING AND ALLIED HEALTH DIVISION
Revised October 2010
COURSE SYLLABUS
HE-225 Health Data Content and the Computer Based Record
Instructor:
Phone:
E-mail:
Joann Miller, BS, RHIA
(423) 697-2582
joann.miller@chattanoogastate.edu
Class Hours/Credit Hours: 3 HRS Lecture / 3 Credit HRS
Semester: Spring 2010
Room: Health Science Center 2106
Catalog Course Description: This course emphasizes JCAHO, NCQA, Medicare, and state licensure requirements including medical staff
credentialing; the course stresses documentation issues. Data sets utilized to measure healthcare such as UHDDS, UACDS, MDS, HEDIS, and
NPDB are covered. Cancer and Trauma registries, primary versus secondary records, data dictionaries, forms design, and screen design are
reviewed. The CPR (computer-based patient record) is introduced.
Pre-requisite: HE-115 or instructor’s consent.
Corequisite: None
Entry Level Standards: College level reading, writing, and math
Please Note: To fulfill degree requirements, health information management students must have an overall grade of 70% or better.
Textbooks:
Hamilton, B. Electronic Health Records, New York, New York: McGraw Hill Higher Education.
Abdelhak, M. Health Information: Management of a Strategic Resource, (3rd ed.), St. Louis, Missouri: Saunders-Elsevier.
Chapters: 1 –Health Care Systems
6 – Classification Systems, Clinical Vocabularies, and Terminology
3 –Health Information Infrastructure & Systems 8 –Technology, Applications, and Security
4 –Health Data Concepts (min.data sets)
9 –Information Systems Life Cycle and Project Management
5 – EIectronic Health Record Systems
14—Data Analysis and Use
Supplementary Material:
As identified by instructor.
College Competencies
Chattanooga State Community College has identified college-level competencies and student learning outcomes that it expects the
graduates of its educational programs to have attained at appropriate levels for each program These outcomes reflect the knowledge,
skills and attitudes that a community college graduate is expected to have developed, including:
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HE-225 syllabus.rev.01-09
Effective Communication: Includes speaking, writing and graphic presentation skills
Critical Thinking and Analytical Skills: Purposeful, self-regulatory judgment which results in interpretation,
analysis, evaluation, and inference, as well as explanation of the evidential, conceptual, methodological,
criteriological, or contextual considerations upon which that judgment is based.
Information Technology Skills: Includes use of computers, online learning, information seeking, and use of new
technologies.
Societal & Cultural Awareness: Includes awareness of how societal and cultural differences affect an individual’s
life, focusing on diversity and collaboration.
Competence in a Specialty: The specialty-specific competencies that each graduate of the program is expected
to achieve.
Work Ethic
Revised October 2010
Required Student Learning Outcomes (Program Student Learning Outcomes and Course Student Learning Outcomes):
The student will be instructed in areas of knowledge, skills, and attitudes that will demonstrate the required competencies as
documented in the American Health Information Management Association’s document entitled, “HIM Associate Degree Entry-Level
Competencies: Domains, Subdomains, and Tasks.”
The AHIMA domains, sub-domains, and competency tasks for RHITs addressed in this course include:
PSLO 1 Health Data Management
CSLO 1. Collect and maintain health data (such as data elements, data sets, and databases)
CSLO 2. Conduct analysis to ensure documentation in the health record supports the diagnosis and reflects the patient’s progress,
clinical findings, and discharge status
CSLO 3. Apply policies and procedures to ensure the accuracy of health data.
CSLO 4. Contribute to the definitions for and apply clinical vocabularies and terminologies used in the organization’s health
information systems
CSLO 5. Verify timeliness, completeness, accuracy, and appropriateness of data and data sources for patient care, management,
billing reports, registries, and/or databases
CSLO 6. Monitor the accuracy and completeness of the health record as defined by organizational policy, external regulations and
standards
CSLO 7. Apply policies and procedures to ensure organizational compliance with regulations and standards
CSLO 8. Report compliance findings according to organizational policy
CSLO 9. Maintain the accuracy and completeness of the patient record as defined by organizational policy and external regulations
and standards
CSLO 10. Assist in preparing the organization for accreditation, licensing, and/or certification surveys
PSLO 2 Health Statistics, Biomedical Research, and Quality Management
CSLO 11. Abstract and maintain data for clinical indices/databases/registries
CSLO 12. Collect, organize, and present data for:
a. Administrative purposes
b. Financial purposes
c. Performance improvement programs
d. Quality management
PSLO 3 Health Services Organization and Delivery
CSLO 13. Comply with accreditation, licensure, and certification standards from government (national, state, and local levels) and
private organizations (such as Joint Commission on the Accreditation of Healthcare Organizations)
CSLO 14. Apply policies and procedures to comply with the changing regulations among various payment systems for healthcare
services such as Centers for Medicare and Medicaid Services (CMS), managed care
CSLO 15. 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
PSLO 4 Information Technology and Systems
CSLO16. Use technology, including hardware and software, to ensure data collection, storage, analysis, retrieval and reporting of
Information
CSLO 17. Use common software applications (such as spreadsheets; databases; presentation; e-mail ) in the execution of work
processes
CSLO 18. Use specialized software in the completion of HIM processes (such as chart management; coding; release of information)
CSLO 19. Apply policies and procedures for the use of networks, including intranet and internet applications to facilitate the electronic
health record (PHR), public health, and other administrative applications
CSLO 20. Apply knowledge of data base architecture and design (such as data dictionary, data modeling, data warehousing, and so
on) to meet departmental needs
CSLO 21. Use appropriate electronic or imaging technology for data/record storage
CSLO 22. Query and generate reports to facilitate information retrieval
CSLO 23. Design and generate reports using appropriate software
CSLO 24. Maintain archival and retrieval systems for patient information stored in multiple formats
CSLO 25. Coordinate, use and maintain systems for document imaging and storage
CSLO 26. Apply confidentiality and security measures to protect electronic health information
CSLO 27. Protect data integrity and validity using software or hardware technology
CSLO 28. Apply departmental and organizational data and information system security policies
CSLO 29. Use and summarize data compiled from audit trail and data quality monitoring programs
HE-225 syllabus.rev.01-09
Revised October 2010
CSLO 30. Contribute to the design and implementation of risk management, contingency planning, and data recovery procedures
CSLO 31. Participate in the planning, designing, selection, implementation, integration, testing, evaluation, and support for
organization-wide information systems
CSLO 32. Use the principles of ergonomics and human factors in work process design
AHIMA knowledge clusters covered in this course are:
KCC Health Data Structure, Content and Standards
KCC Healthcare Information Requirements and Standards
KCC Healthcare Statistics and Research
KCC Information and Communication Technologies
KCC Data Storage and Retrieval
KCC Data Security and Healthcare Information Systems
Other Learning Indicators or Objectives:
1- Identify and describe the regulators of health care, including government and non-government entities.
2- Outline the role of the federal, state, and local governments in the provision of health care.
3- Interpret standards published by regulatory agencies.
4- Discuss the purpose of surveys by regulatory agencies.
5- Discuss the process by which health care facilities are surveyed to insure compliance with the Conditions of Participation.
6- Define key concepts and acronyms, including accreditation, licensure, certification, CMS, DHHS, Joint Commission, etc.
7- Describe the accreditation process of Joint Commission and other bodies. Identify and interpret accreditation standards.
Apply those standards to a given facility (scenario) and make a determination of that facility’s compliance with standards.
8- Evaluate a health information management department based on regulatory standards.
9- Identify key concepts related to Medical Staff Credentialing, including appointment, credentialing, privilege delineation. Identify
external requirements for credentialing, and types of medical staff membership and responsibilities. Explain the relationship
between organizational policies and procedures and medical staff by-laws.
10- Define the National Practitioners Data Bank and the process for utilizing.
11- Define the responsibilities of the credentials committee and the governing board.
12- Define data elements, data sets and databases. Explain the purpose and/or need for defined data sets. Identify various
datasets and explain their relationship to the medical record, eg. UHDDS, UACDS, Minimum Data Set, National Cancer Data
Bank, Uniform Clinical Data Set, Hospital Discharge Databases, Health Plan Employer Data and Information Set.
13- Identify the relationship between data collection and forms. Apply knowledge of defined data sets and regulatory standards to
forms design, content, data usage (in both a manual and/or electronic format).
14- Abstract and maintain data for clinical indices, databases, and registries (in both a manual and/or electronic format).
15- Define secondary records; identify specific secondary records retained in an HIM department (indices, registers, logs) and
Indicate when they would be used.
16- Identify registers and logs maintained by other departments and the purpose of each, the department responsible for
maintaining and types of information/data contained. (ED,OR, MD, Diagnostic, Procedural, etc.)
17- Define different registries including Tumor, Trauma, Vital Statistics, and explain the required reporting, the agencies involved
with these processes, and the collection of data.
18- Identify the stages in information systems development life cycle.
19- Understand and apply techniques for gathering information for system design and implementation. Identify facility needs.
Evaluate potential systems based on the information gathered and perceived needs. Understand the process involved with
selection and purchase of a system, including development of a request for proposal (RFP). Develop a plan for implementation.
20- Define key concepts as they pertain to the electronic health record.
21- Explain the difference between an electronic health record and an imaging program.
22- Explain the fundamental purposes of health information systems. Review the historical development of health information
systems as fore-runner to computer-based patient record systems. Describe landmark efforts in computer-based patient record
developments.
23- Explain ASTM E 1384 and its relation to the computer-based patient record and data collection.
24- Differentiate between retrospective record completion and point-of-service documentation.
Required Assessments:
Assessment Names and Descriptions:
1. Practice and Participation (P&P): 20% of grade (PSLO 1, PSLO 2, PSLO 3, PSLO 4, CSLO 1-32)
Students are assessed weekly on attendance, participation, and in-class work
2.Assignments (A): 20% of grade
1-Making Data Meaningful article (PSLO 2, CSLO 11)
2-EHR article (PSLO 2, PSLO 4, CSLO 11, 12, 16-32)
HE-225 syllabus.rev.01-09
Revised October 2010
3-E-signing (PSLO 1, CSLO 7)
4-Lab 1- Gartee (PSLO 1, PSLO 2, PSLO 3, PSLO 4, CSLO 1-32)
5-Lab 2-Springhouse (PSLO 1, PSLO 2, PSLO 3, PSLO 4, CSLO 1-32)
6-Lab 3-Comparison & Contrast (PSLO 1, PSLO 2, PSLO 3, PSLO 4, CSLO 1-32)
7-Lab 4-VISTA (PSLO 1, PSLO 2, PSLO 3, PSLO 4, CSLO 1-32)
3.Exams & Quizzes (Exam/Quiz): 20% of grade
Quiz 1 (PSLO 1, CSLO 4)
Exam 1 (PSLO 1, PSLO 2, CSLO 1-10, 12)
Quiz 2 (PSLO 4, CSLO 16-20)
4.Project: 20% of grade (PSLO 1, PSLO 2, PSLO 4, CSLO 1, 4, 11, 12, 16-23)
Access Database Project—Students build a simple database with corresponding data dictionary, and then perform assorted reports &
queries. Students analyze the results of the reports & queries, translate the results into graphic form, and postulate reasons for the
results. This postulation brings the students’ learning full-circle as they then develop potential solutions to remediate the results.
5.Final Exam: 20% of grade (PSLO 1, PSLO 2, PSLO 3, PSLO 4, CSLO 1-32)
Comprehensive final exam assesses student learning over the entire semester’s course material.
CSLO/Assessment Alignment:
CSLO #1
CSLO #2
P&P
P&P
A4-7
A4-7
Exam 1
Exam 1
Project
Final
Final
CSLO #3
P&P
A4-7
Exam 1
Final
CSLO #8
P&P
A4-7
Exam 1
Final
CSLO #9
P&P
A4-7
Exam 1
Final
CSLO #10
P&P
A4-7
Exam 1
Final
CSLO #4
P&P
A4-7
Quiz 1
Exam 1
Project
Final
CSLO #11
P&P
A1,2,4-7
Project
Final
CSLO #15
P&P
A4-7
Final
CSLO #16
P&P
A2, 4-7
Quiz 2
Project
Final
CSLO #23
P&P
A2, 4-7
Project
Final
CSLO #30
P&P
A2, 4-7
Final
CSLO #17
P&P
A2, 4-7
Quiz 2
Project
Final
CSLO #24
P&P
A2, 4-7
Final
CSLO #18
P&P
A2, 4-7
Quiz 2
Project
Final
CSLO #25
P&P
A2, 4-7
Final
CSLO #31
P&P
A2, 4-7
Final
CSLO #32
P&P
A2, 4-7
Final
CSLO #22
P&P
A2, 4-7
Project
Final
CSLO #29
P&P
A2, 4-7
Final
CSLO #5
P&P
A4-7
Exam 1
Final
CSLO #6
P&P
A4-7
Exam 1
Final
CSLO #7
P&P
A3, 4-7
Exam 1
Final
CSLO #12
P&P
A2, 4-7
Exam 1
Project
Final
CSLO #19
P&P
A2, 4-7
Quiz 2
Project
Final
CSLO #26
P&P
A2, 4-7
Final
CSLO #13
P&P
A4-7
Final
CSLO #14
P&P
A4-7
Final
CSLO #20
P&P
A2, 4-7
Quiz 2
Project
Final
CSLO #27
P&P
A2, 4-7
Final
CSLO #21
P&P
A2, 4-7
Project
Final
Grading Scale or Policy, Weekly Outline, Topics, or Instructional Activities:
Date:
Week 1
Week 2
Week 3
Week 4
Topic:
Introduction and Syllabus Review
Health Care Systems (Review of Regulatory Agencies and Organizations)
Hlth Info Infrastructure (Ch. 3) and Health Data Concepts(min.data sets)
Electronic Health Record Systems (Ch. 5)
Classification Systems, Clinical Vocabularies, & Terminology (Ch. 6)
Quiz # 1
Technology, Applications, and Security (Ch. 8)
HE-225 syllabus.rev.01-09
CSLO #28
P&P
A2, 4-7
Final
Week 5
Week 6
Week 7
Week 8
Week 9
Week 10
Week 11
Week 12
Week 13
Week 14
Week 15
Week 16
Information Systems Life Cycle and Project Management (Ch. 9)
Data Analysis and Use (Ch. 14)
Exam # 1
Intro to Electronic Health Records (Ch.1, 2 & 3)
No Class – Spring Break
Electronic Health Records (Meet in HIM Lab, Ch. 4 & 5)
Electronic Health Records (Meet in HIM Lab, Ch. 6 & 7)
Working Class—Research for Paper/Project (to be announced)
Quiz # 2
Electronic Health Records (Meet in HIM Lab, Ch. 8 & 9)
Electronic Health Records (Meet in HIM Lab, Ch. 10, 11 & 12)
Exam Review
Final Exam (Details re: Time, Date & Location to be announced)
Grading Scale
90-100
80-89
70-79
65-69
0-64
Revised October 2010
A
B
C
D
F
Please Note:
**Points are deducted for late submission of assignments.
**All make-up exams are to be taken within 7 calendar days of the original administration (test) date.
Instructional Activities
1-Class lecture:
2-Assignments (including web-site review & presentation, electronic systems review & analysis, and textbook reading):
3-In-class assignments, including hands-on activities in the electronic record:
4-Class discussion:
5-Assessments:
Required Classroom/College Policy Statements:
Course Delivery Format
Faculty will require on-line activities and assignments to include on-line tests and submission of all written and on-line communications.
Standard Format – This format is the traditional format and will use an online format to provide access to “static” materials which
include the syllabus, course material, contact information, and presentations. Faculty must make available when requested a copy of
syllabus and any other instructor provided course materials, including their contact information. Faculty will require on-line activities
and assignments to include online tests and submission of all written and on-line communications.
Students must access course content and assessments using the Internet in order to pass the class. Reading assignments and
semester assignments are posted in eLearn. The majority of graded assignments will be completed using eLearn and submitted
through the Dropbox. Quizzes and exams will be conducted in the traditional manner, in the classroom, proctored by the instructor.
Course-related information and instructor updates regarding class topics, such as the syllabus, assignments, tests, and dates will be
posted in eLearn.
College Policies
ADA Statement:
Students who have educational, psychological, and/or physical disabilities may be eligible for accommodations that provide equal
access to educational programs and activities at Chattanooga State. These students should notify the instructor immediately,
and should contact Disabilities Support Services (S-113, phone 697-4452) within the first two weeks of the semester in order
to discuss individual needs. The student must provide documentation of the disability so that reasonable accommodations can be
requested in a timely manner. All students are expected to fulfill essential course requirements in order to receive a passing grade in
a class, with or without reasonable accommodations.
HE-225 syllabus.rev.01-09
Revised October 2010
Disruptive Students:
The term “classroom disruption” means behavior a reasonable person would view as substantially or repeatedly interfering with the
conduct of the class. A student who persists in disrupting a class will be directed by the faculty member to leave the classroom for the
remainder of the class period. The student will be told the reason(s) for such action and given an opportunity to discuss the matter
with the faculty member as soon as practicable. Prompt consultation will be taken by the faculty member with the Department Dean
and the College Judicial Officer. If a disruption is serious and other reasonable measures have failed, the class may be adjourned and
campus police summoned.
Affirmative Action:
If you have complaints or feel you have not received equal access to educational programming, please contact Jerome Gober,
Affirmative Action Officer, at 697-4457.
Communications:
The official method for all Chattanooga State communications to students is via Chattanooga State e-mail. Please note students
should check this e-mail periodically to be updated on all financial aid and records issues.
Course-related information and instructor updates regarding class topics, such as the syllabus, assignments, tests, and dates will be
posted in e-learn.
Academic Integrity / Academic Honesty
In their activities, students are expected to maintain high standards of honesty and integrity. Academic dishonesty is prohibited. Such
conduct includes, but is not limited to, an attempt by one or more students to use unauthorized information in the taking of an exam, to
submit as one’s own work, themes, reports, drawings, laboratory notes, computer programs, or other products prepared by another
person, or to knowingly assist another student in obtaining or using unauthorized materials. Plagiarism, cheating, and other forms of
academic dishonesty are prohibited. Students guilty of academic misconduct, either directly or indirectly through participation or
assistance, are immediately responsible to the instructor of the class. In addition to other possible disciplinary sanctions, which may
be imposed through the regular institutional procedures as a result of academic misconduct, the instructor has the authority to assign
an “F” or zero for an activity or to assign an “F” for the course.
The instructor reserves the right to modify this syllabus in writing during the course of the semester.
Instructor Absence:
In the event of a scheduled instructor absence, a substitute instructor, an alternate out-of-class assignment, or a lab assignment
appropriate to the class will be provided. In case of an emergency instructor absence, every effort will be made to provide an
appropriate out-of-class assignment or lab, posted in e-learn
Class Schedule:
Lecture: Wednesday Afternoons, Noon to 2:40 pm, Health Science Center, Room 2106 or 2108
Instructor Information:
Instructor:
Office Location:
Office Number:
Fax:
E-mail:
Joann Miller, RHIA
Health Science Center, Room 2070; Office hours as posted
697-2582
634-3071
joann.miller@chattanoogastate.edu
HE-225 syllabus.rev.01-09