Health Information Management
Program (HIM)
Student Handbook
2014/2015
*This handbook is designed to serve as a supplement to the MOE Handbook. This handbook
may be accessed through the following link:
http://www.medaille.edu/files/pdf/academics/2013-14_moe_student_handbook_and_catalog.pdf
Table of Contents
Welcome from the Program Director ................................................................... 2
Program Mission Statement ............................................................................... 3
Program Goals and Objectives ........................................................................... 3
Accreditation Status ....................................................................................... 4
Advisory Board .............................................................................................. 4
Health Information Administration Course Sequences ............................................. 5
Program Goals ............................................................................................... 5
Bachelor of Professional Studies in HIA Core Sequence and Course Descriptions ............ 6
Bachelor of Professional Studies in HIA Bridge Sequence and Course Descriptions ........ 10
Professional Practice Experience (PPE) ............................................................. 12
a.
Technical Experience (Virtual Lab) ............................................................ 12
b.
Management Experience ......................................................................... 12
1. Costs ........................................................................................... 13
2. Professional Liability Requirements ....................................................... 13
3. Physical Exam Requirements ............................................................... 13
4. Dress Code ..................................................................................... 13
AHIMA ....................................................................................................... 14
Appendices ................................................................................................ 15
a. CAHIIM Curriculum Requirements-AHIMA 2011 Curriculum Competencies and
Knowledge Clusters .................................................................................... 16
b.
Bloom’s Taxonomy ................................................................................ 30
c.
AHIMA Code of Ethics ............................................................................ 31
d.
Confidentiality Statement ...................................................................... 41
1 Welcome to Medaille College!
I am pleased to welcome you to the Health Information Management (HIM) program at
Medaille College! Our unique accelerated learning program in HIA is totally online, with
coursework that is stimulating, challenging, and reflective of the ever-changing field of HIM.
We are happy that you chose both Medaille College and the Bachelor of Professional Studies
(BPS) degree in Health Information Management and look forward to working with you. We
are very proud of our faculty; every instructor is a professional in his/her field of expertise,
bringing knowledge and extensive experience to the online learning environment.
This handbook contains the course sequence and curriculum, as well as providing an overview
of what to expect from the program and your responsibilities therein. It serves in conjunction
with the following additional handbooks:
•
•
Medaille Online Experience Student Handbook and Catalog, which includes policies
and procedures, is available at: http://www.medaille.edu/files/pdf/academics/201314_moe_student_handbook_and_catalog.pdf.
The ALP Guide to Collaborative Learning Teams, which can be accessed at:
http://www.medaille.edu/files/pdf/academics/2013_alp_guide_to_collaborative_lear
ning_teams.pdf , provides support and instruction for learning teams.
Again, thank you for giving us the opportunity to assist you with your career in HIM! If you
have any questions, please feel free to contact me or your academic advisor.
Best of luck!
Teresa M. Reinhardt, MBA, RHIA
Program Director, HIM Program
Clinical Assistant Professor
School of Adult and Graduate Education (SAGE)
18 Agassiz Circle
Buffalo, NY 14214
(716) 932-2558 office
(716) 912-9929 cell
teresa.m.reinhardt@medaille.edu
2 Program Mission Statement
In alignment with the mission of Medaille College, the Health Information Management (HIM)
program is dedicated to providing students with a comprehensive, current, and real-world
experience in Health Information Management. We are committed to developing in our
students both proficiency in the competencies, skills, and knowledge of health information
management, while enhancing their skills in analytical and critical thinking, decision making,
and ethical integrity.
HIM Program Goals and Objectives – 2014-2015
Program Goal
1.
To develop proficiency in the
competencies, skills, and knowledge
of health information management,
including privacy and security, health
databases, principles of management
and leadership, professional
certification, and computer
technologies.
Objectives/Outcomes
a.
b.
c.
d.
e.
f.
2.
3.
4.
5.
6.
To develop in all students the
interpersonal skills necessary for
effective participation in teams and
groups.
To enhance the analytical, critical
thinking, and decision-making skills of
each individual student.
To develop and cultivate a sense of
responsibility and ethical behavior in
each student.
To enhance the student’s written and
spoken communication skills.
To develop proficiency in the
application of information systems.
g.
HIA students will review regulatory changes in privacy and
security.
HIA students will retrieve, analyze, and compare health
data such as data elements, data sets, and databases.
HIA students will use management and leadership skills to
effectively develop and motivate human resources and to
plan and manage the daily operation of an HIM
department.
HIA students will analyze the benefits and demands of
professional certification.
HIA students will effectively access appropriate healthcare
databases.
HIA students will analyze and compare case studies that
focus on ethical decision making.
HIA students will work and communicate effectively with
team members in a professional manner, including
members of diverse backgrounds and attitudes.
h.
HIA students will analyze quantitative and qualitative data
in order to evaluate outcomes.
i. HIA students will analyze data using statistical tools.
j. HIA students will examine the role of ethics in healthcare
and formulate their personal professional ethical
statement.
k. HIA students will demonstrate proficiency in
communication through a variety of virtual individual and
group presentations.
l. HIA students will implement and manage use of
technology, including hardware and software to insure data
collection, storage, analysis, and reporting of information.
m. HIA students will implement and manage knowledge-based
applications to meet end-user information requirements.
n. HIA students will use clinical vocabularies and
terminologies employed in healthcare information systems.
3 Accreditation
The program is accredited by the Commission on Accreditation for Health Informatics and
Information Management Education (CAHIIM). For more information, visit: www.cahiim.org.
Graduates and final term students are eligible to register for the national Registered Health
Information Administrators (RHIA) credential examination offered by the American Health
Information Management Association (AHIMA).
Advisory Board
The HIM Advisory Board is comprised of professionals
from various aspects of the field who share an
interest in health information management and want
to participate in curriculum review and provide
recommendations for change or improvement. Its
members represent a many of the organizations in
the area. Meetings are held at least once a year.
2014-15 Medaille College
HIA Advisory Board
Deborah Robinson
Fraud investigator, Special Investigation Unit
Independent Health
Jennifer Fairbairn, RHIT
Senior Corporate Coding Specialist
Roswell Park Cancer Institute
Kris Spada, RHIA
HIM Manager, Millard Fillmore Suburban and
DeGraff Hospitals
Kaleida Health System
Mary Beth McCarthy, RHIA, CIRCC
Director, Coding Integrity and Health
Information
Catholic Health System
Matthew Greene, RHIA, CCS
EHR Certification/Meaningful Use Specialist
Veterans Health Administration
Office of Informatics and Analytics (OIA)
Kim Faulhaber, MS, RHIA
Outcomes Manager, Behavioral Health
Erie County Medical Center Corporation
Karen Bettino, BS, RN
Administrative Director HIM and Registry
Network Services
Roswell Park Cancer Institute
Elizabeth Zivis, BSN, RN, RHIA
Director, HIM/Privacy Officer
Erie Country Medical Center
Susan Ruhland, RHIT
HIM and Accounts Receivable Manager
Buffalo Ambulatory Center
4 Health Information Management Course Sequences:
Medaille’s Bachelor of Professional Studies in Health Information Administration (BPS-HIA)
program is built around a 60-credit core sequence that was developed to prepare qualified
individuals to become a Registered Health Information Administrator (RHIA). As technology
becomes more and more important in using and maintaining medical records, the role of the
health information professional becomes increasingly critical. The BPS HIA prepares students
to collect, maintain, interpret, analyze and protect essential medical data. This accelerated online degree completion sequence is offered through Medaille Online
Experience (MOE). MOE programs are developed for working adults who have already earned
college credits, have significant full-time work experience, and can demonstrate at least a
minimum level of academic or professional experience. Additional information on MOE
pedagogy is available in the Medaille Online Experience Student Handbook. Students must
have the use of an appropriate computer and Internet connection throughout the program.
Students entering the BPS HIA degree completion sequence must have earned an associate’s
degree in health information technology or have completed equivalent courses in all required
areas. Students without an HIT degree who wish to earn the BPS-HIA may enter the BPS-HIA
Bridge, which offers those health information technology/health information administration
classes required for entry into the Core sequence. Students with a previous background in
biomedical sciences or business administration may be able to challenge or waive specific
courses.
Program Goals
The Bachelor of Professional Studies in Health Information Administration (BPS HIA)
prepares students to collect, maintain, interpret, analyze and protect medical data that is
essential for providing effective and efficient health care. The program includes courses in
coding and classification systems, management of patient health information, and
administration of computer information systems.
1. To develop proficiency in the competencies, skills, and knowledge of health
information management, including privacy and security, health databases, principles
of management and leadership, professional certification and computer technologies.
2. To develop in all students the interpersonal skills necessary for effective participation
in teams and groups.
3. To enhance the analytical, critical thinking, and decision-making skills of each
individual student.
4. To develop and cultivate a sense of purpose, responsibility, and ethical behavior
among individuals, especially in regard to the legal and ethical issues related to
protected health information
5. To enhance the student’s written and spoken communication skills.
6. To develop proficiency in the use of computer technologies.
5 Bachelor of Professional Studies in Health Information Management
Core Sequence
Course
Description
Credits Weeks
GEN 310
Critical Thinking and Online Studies
4
7
HIA 321
Health Information Management: Theory and Practice
4
7
HIA 322
The Legal Health Record
4
7
HIA 330
Information Systems & Technology
4
7
HIA 334*
The Electronic Health Record
4
7
BIO 312
Pathophysiology and Pharmacology I
4
7
BIO 313
Pathophysiology and Pharmacology II
4
7
HIA 405*
Managing the Coding Process for Inpatients
4
7
HIA 406*
Managing the Coding Process for Outpatients
4
7
HIA 407*
Reimbursement Methodologies
4
7
HIA 408
Financial and Revenue Cycle Management
4
7
HIA 333
Healthcare Statistics, Research, and Quality Improvement 4
7
HIA 440
Management and Organization for Health Professionals
4
7
HIA 460
Professional Practice Management Capstone
4
7
HIA 470
Professional Review and Certification
4
7
60
105
TOTALS
* Electronic lab sessions in these courses constitute part of the overall professional
practice experience (PPE)
6 Bachelor of Professional Studies in Health Information Management
Core Course Descriptions
BIO 312
Pathophysiology and Pharmacology I
4 credits, 7 weeks
This course is the first half of a detailed investigation into pathophysiology and pharmacology.
Students examine the biological and physical manifestations of a wide variety of diseases and
conditions, the appropriate medical procedures, and the related pharmacology, as well as the
ways in which this information is used in coding, medical transcription, and data analysis.
Pathophysiology and Pharmacology I examines basic pharmacology and pathophysiology
concepts; infectious diseases; endocrine, deficiency, and immunity disorders; mental
disorders; the nervous system; sense organs; and the cardiovascular system.
BIO 313
Pathophysiology and Pharmacology II
4 credits, 7 weeks
This course is the second half of a detailed investigation into pathophysiology and
pharmacology. Students examine the biological and physical manifestations of a wide variety
of diseases and conditions, the appropriate medical procedures, and the related
pharmacology, as well as the ways in which this information is used in coding, medical
transcription, and data analysis. Pathophysiology and Pharmacology II examines the
respiratory system, the digestive system, the integumentary system, the musculoskeletal
system, the genitourinary system, obstetrics and newborns, as well as injury and trauma.
GEN 310
Critical Thinking and Online Study
4 credits, 7 weeks
This course provides an introduction to the expectations and methodology of college-level
online learning and critical thinking. Through readings, discussion, and writing assignments,
the course examines critical thinking and communication skills as they are used in the analysis
of significant ideas. The course specifically addresses the challenges of online self-directed
learning, the demands of online communication, the conventions of academic research, and
the study and personal skills required for success as an adult student. Study team dynamics,
library orientation, and learning style assessment are also included.
HIA 321
Health Information Management: Theory and Practice 4 credits, 7 weeks
This course provides the student with knowledge of the organization and delivery of
healthcare systems and the concepts, principles, rules and regulations that govern HIM
operations. Students will examine documentation requirements, timeliness, and
completeness of the health record, with emphasis placed on the transition to the Electronic
Health Record (EHR). Students will also review record content requirements mandated by
accrediting and regulatory agencies and various legal requirements in maintaining health
records, as well as investigate various registries and indexes and the role HIM has in
maintaining them.
HIA 322
The Legal Health Record
4 credits, 7 weeks
This course provides an overview of the U.S. legal system, processes, and actions encountered
in healthcare. Students will become familiar with the legal health record, e-discovery
guidelines, and related agencies or external entities that influence both the healthcare
environment and the HIM profession. Topics include access and disclosure of personal health
information (PHI), various legal healthcare documents, HIPAA privacy, security and breaches,
and compliance with subpoenas. The course also analyzes the effectiveness of compliance
programs, including governmental audits, coding compliance, HIPAA Privacy and Security
audit programs, and the Office of the Inspector General (OIG) as it relates to healthcare
7 compliance. Ethical standards of practice in health information management (HIM) such as
coding are also examined.
HIA 330
Information Systems & Technology
4 credits, 7 weeks
This course provides the student with in-depth knowledge regarding the implementation and
management of various technology systems utilized in the healthcare industry. Students will
be introduced to the hardware and software available to ensure data integrity and security.
Additionally, the principles and concepts learned will assist with the development of various
networks, intranet, internet, electronic health record (EHR), personal health record (PHR),
public health and other administrative systems.
HIA 333
Healthcare Statistics, Research, & Quality Improvement 4 credits, 7 weeks
This course applies high-level statistical management skills to HIM operations, health
research, and quality management and performance improvement. Students will analyze
data to identify trends, manage risk, optimize utilization, and facilitate decision making.
Students will also examine basic research designs and methodology used in HIM and
organization-wide operations.
HIA 334
The Electronic Health Record
4 credits, 7 weeks
This course presents a detailed overview of the various technologies and systems used to
handle and store medical records data, provide and enforce security, and maintain accurate
and reliable systems. Course topics cover the hardware and software needed to ensure data
collection, storage, analysis, and reporting. Networks, including intranet and internet
applications, are examined as they contribute to the administration of electronic medical
records. Special attention is given to the issues of privacy and security (HIPAA), which
include data security concepts, contingency planning, audit trails, and the use of technology
to secure data integrity and validity. Processes and procedures regarding the proper use and
disclosure of healthcare data as well as the concept of interoperability will be investigated.
HIA 405
Managing the Coding Process for Inpatients
4 credits, 7 weeks
This course focuses on the medical coding system of ICD-10-CM and ICD-10-PCS as well as the
application of these systems to hospital inpatient services reporting. Students will examine
and apply key functions related to the coding process. Inpatient reimbursement processes,
including the documentation improvement process, management of inpatient coding quality
using audit techniques, and coding resources and tools (i.e. encoders and groupers) will also
be addressed.
HIA 406
Managing the Coding Process for Outpatients
4 credits, 7 weeks
This course focuses on the medical coding system of CPT (Current Procedural Terminology)
and HCPCS and the application of these systems to all outpatient services reporting. Students
will examine key functions related to the coding and outpatient reimbursement process,
including documentation issues, coordination of the reimbursement process, use of Charge
Description Master (CDM), management of outpatient coding quality in a variety of outpatient
settings, and outpatient reimbursement systems. Compliance strategies to meet Federal and
other regulatory requirements for the outpatient services will be developed and utilized.
HIA 407
Reimbursement Methodologies
4 credits, 7 weeks
This course includes a review of health care reimbursement systems for all patient services.
Students will review health insurance basics and apply the concepts to a variety of patient
8 and payer types in order to calculate accurate health care reimbursements using federal and
state edits, compliance techniques, and resources. Unique patient types and services such as
home care, skilled nursing care, Medicare, and Medicaid insurance are included.
HIA 408
Financial and Revenue Cycle Management
4 credits, 7 weeks
This course provides an overview of the financial concepts required by the health information
professional: basic accounting reports, budgeting, contracts,, and specific healthcare data
management that is directly related to the revenue cycle, including coding, and
reimbursement. Students will also review basic accounting and financial management
principles, the history of reimbursement methodologies, and how healthcare data plays an
increasingly important role in the revenue cycle. The course will focus on the impact of
documentation improvement as it relates to ICD-10.
HIA 440
Management and Organization for Health Professions 4 credits, 7 weeks
This course will investigate best practices in human resources, project, and operations
management (including process improvement and quality assurance in healthcare), and
managing workplace teams. Special emphasis is placed on recruiting, training, and
motivating employees. Basic strategic planning and management concepts will be applied to
projects specific to the HIM department. Concepts of change management and emotional
intelligence are applied to the management of the HIM department. This course is a prerequisite to HIA 460.
HIA 460
Professional Practice Management Capstone
4 credits, 7 weeks
This course is a final management capstone experience and is intended to provide a complete
integration and application of previous course work and virtual lab experience in the HIA
CORE course sequence. Students will engage in a management experience which focuses on a
specific project. Developed in cooperation with the HIA Program Director and the designated
site, the capstone project will require demonstration of management capabilities, problem
solving, critical thinking, and an understanding of HIM concepts and practices.
HIA 470
Professional Review and Certification
4 credits, 7 weeks
Within this course, student will review, synthesize, and evaluate skills and content from
previous BPS HIA courses. Students will investigate areas of individual interest and
proficiency, as well as professional opportunities within the current HIA market. The course
will include partial and complete mock competency exams.
9 Bachelor of Professional Studies in Health Information Management
Bridge Course Sequence
Course
Description
Credits Weeks
HIA 197
Essentials of Healthcare Delivery
4
7
HIA 198
Health Information Technology
4
7
MAT 203
Statistics for Today’s Business
4
7
HIA 123
Medical Terminology
4
7
BIO 140
Introductory Human Anatomy and Physiology I
4
7
BIO 141
Introductory Human Anatomy and Physiology II
4
7
24
42
Totals
HIA 197
Essentials of Healthcare Delivery
4 credits, 7 weeks
This course covers the essential elements of healthcare delivery in the United States, providing
an overview of health care policy and its development. Course topics include the resources and
systems used in delivering health care, including outpatient and primary care services, hospitals,
managed care, long term care, and populations with special needs. Students will evaluate the
outcomes of our health care system and how they are addressed through health care policy. The
future of healthcare in the United States is discussed and analyzed, including health reform, cost
and access, public health, and technology.
HIA 198
Health Information Technology
4 credits, 7 weeks
This course investigates the function and purpose of both the Health Information Management
(HIM) Department and the health record. Students will explore HIM professional
opportunities, the history of health information management, and the role of HIM in the
healthcare team. Course activities will focus on the health record, including its purpose,
function, content, and structure, as well as the role of the HIM professional in maintaining
the record. The course will also provide a brief introduction into privacy and confidentiality
issues regarding the health record.
MAT 203X
Statistics for Today’s Businesses
4 credits, 7 weeks
This course presents an introduction to data collection and interpretation, descriptive and
inferential statistics, sampling, hypothesis testing, and probability distribution as they apply
to business planning and decision making. Emphasis is placed on the use of statistical
software for data analyses and the ethical uses of statistics.
10 HIA 123
Medical Terminology
4 credits, 7 weeks
This course introduces students to the language of medicine utilized by health care
professionals within various healthcare settings, when diagnosing and treating various
diseases and conditions. Students will identify the various components of medical terms (i.e.
roots, suffixes, and prefixes) when building and dissecting these terms.
BIO 140
Introductory Human Anatomy and Physiology I
4 credits, 7 weeks
This course provides an introduction to the cell and tissue levels of organization of the
skeletal, muscular and nervous systems of the human body including the physiology of those
systems and their interrelationships. Students will engage in a series of online laboratory
activities in order to clarify, apply, and enhance course concepts.
BIO 141
Introductory Human Anatomy and Physiology II
4 credits, 7 weeks
This course is a continuation of BIO 140. Topics include the endocrine, circulatory, digestive,
lymphatic, respiratory, excretory, and reproductive systems. Students will engage in a series
of online laboratory activities in order to clarify, apply, and enhance course concepts.
11 Professional Practice Experience (PPE)
The Professional Practice Experience (PPE) has been divided into two distinct learning
experiences for this online delivery. Each component – technical experience and management
experience – have been designed to meet CAHIIM accreditation standards while taking into
consideration both the pedagogy and the geographical realities of online learners
Technical Experience: AHIMA’s Virtual Laboratory (vlab)
The more technical components of Medaille’s PPE have been incorporated into the course
sequence and will be taught, practiced, and assessed through AHIMA’s Virtual Laboratory
(vlab). These vlab exercises will begin in HIA 321, the first course of the HIA Core, and
continue on throughout the rest of your courses as appropriate. Students will gain hands on
experience with the Athens/Cerner EHR, Solcom EDMS, Quadramed and 3M encoder products,
Healthport Release of Information, and the Quadramed MPI Suite.
Medaille utilizes AHIMA’s virtual lab to give students hands-on experience with the latest
software and technology available in the HIM field, such as the master patient index (MPI),
Cerner/Athens EHR , 3M and Quantim encoders, electronic document management systems
(EDMS), and Healthport for release of information (ROI). This powerful tool allows students
to gain valuable experience with systems that are used in the field. Exercises are designed
specifically for the lab applications; students gain familiarity with the various applications
they will be using in the field. The cost of vlab is included in the tuition; there is no
additional cost to the students.
Management Experience: Professional Practice Management Capstone
The second PPE component occurs through HIA 460, Professional Practice Management
Capstone. This hands-on capstone experience has been developed for online students and
therefore approaches the learning experience differently than a traditional internship. During
HIA 460, the last course in the Core sequence, each student will be assigned a project by the
Site Supervisor in conjunction with the Program Director at a hospital or other healthcare
organization.
Please note:
• Some projects may require that you spend more time at the site, while others may
require less time spent at the site. Each project is dependent on the site’s needs and
is developed to be mutually beneficial for both the student and the facility. All site
supervisors are aware that this is an online environment and full-time attendance at
their site is not required as in traditional seated programs.
• Please be prepared to take a minimum of 40 hours of time off from work to complete
your Management Capstone. These 40 hours can be distributed throughout the 7 week
period as agreed upon by the site and the student. One day a week for five weeks
may be an acceptable schedule. Please reach out to your site once you know where
you will be placed to discuss your schedule. Sites will begin to be secured while
students are taking HIA333.
12 Prior to HIA 460, the Program Director will work with you to establish both your site and your
project. Students who live outside the Western New York area will be involved in securing a
site for their Management Capstone. Once the arrangements have been finalized and
approved, you will receive official notification of where you will be going and what your
project will be. From that point, you will be communicating directly with the site supervisor.
If you have a preference for a particular site, please notify the HIA Program Director before
the end of HIA 408, Financial and Revenue Cycle Management.
•
Physical Exam Requirements
Since you will be going to a healthcare facility, you will be required to meet their
physical exam requirements and vaccination policies.
•
Dress Code
Students should dress professionally and wear appropriate attire.
•
Costs
Any costs for parking or transportation, as well as any costs involved in the
performance of your management capstone project, are assumed by the student and
are NOT the responsibility of the college.
•
Liability insurance
All students are covered by the college’s liability insurance.
•
Confidentiality and Ethical Behavior
All students are expected to abide by the AHIMA Code of Ethics found in the Appendix.
Signed confidentiality statements are collected and archived prior to starting the
Management Capstone.
13 About AHIMA
The American Health Information Management Association (AHIMA) is the premier association
of health information management (HIM) professionals worldwide. Serving 52 affiliated
component state associations and more than 71,000 members, it is recognized as the leading
source of "HIM knowledge," a respected authority for rigorous professional education and
training.
Founded in 1928 to improve health record quality, AHIMA has played a leadership role in the
effective management of health data and medical records needed to deliver quality
healthcare to the public.
AHIMA is working to advance the implementation of electronic health records (EHRs) by
leading key industry initiatives and advocating high and consistent standards. AHIMA members
stay one step ahead through AHIMA's accreditation of cutting-edge academic programs and
professional development opportunities, including comprehensive continuing education.
AHIMA keeps HIM professionals posted on the healthcare industry through resources to
improve their knowledge, skills, and abilities. Some of AHIMA’s offering include:
•
•
•
•
•
•
•
•
•
Text books
Credentials
Live meetings
Online Education
The Journal of AHIMA
The HIM Body of Knowledge (BoK)
Engage Communities
Newsletters
E-Alerts
In addition to providing resources AHIMA actively advocates for the HIM Profession, serves as a
thought leader in the world of HIM, and is one of the four cooperating parties responsible for
the ICD-10 Coding Guidelines.
AHIMA members affect the quality of patient information and patient care at every touch
point in the healthcare delivery cycle. Our members perform diverse roles in healthcare and
are employed in a variety of work settings, including hospitals, physician offices, ambulatory
care facilities, managed care facilities, long-term care facilities, consulting firms, information
system vendors, colleges and universities, insurance providers, pharmaceutical companies,
rehabilitation centers, and other venues.
http://www.ahima.org/about/aboutahima
14 APPENDICES
Appendix A
Appendix B
Appendix C
CAHIIM Curriculum Requirements
Bloom’s Taxonomy
AHIMA Code of Ethics with Confidentiality Agreement
15 Appendix A CAHIIM Curriculum Requirements
AHIMA 2011 Curriculum Competencies and Knowledge Clusters for
Health Information Management (HIM) Education at
the Baccalaureate Degree Level
Health Information Administration Program/Medaille
Column 3 – For each Knowledge Cluster (curriculum component) state the course # Column 1 -­‐ HIM Baccalaureate Degree Entry-­‐Level Competencies (Student Learning Outcomes) Column 2 -­‐ Knowledge Clusters (Curricular Components) I. Domain: Health Data Management I.A. Subdomain: Health Data Structure, Content, and Standards Health Data Structure, Content, and Acquisition • Capture, structure, and use HIA321 of health information (Evaluating, 5) HIA334 • Health information media HIA321 (paper, electronic) (Evaluating, 5) • Data quality assessment and HIA321 integrity (Evaluating, 5) HIA 408 • Secondary data sources such HIA321 as registries and indexes (Applying, 3) • Healthcare data sets (such as HIA 321 HEDIS, UHDDS, OASIS) (Analyzing, 4) • Health information archival HIA 321 and retrieval systems 1. Manage health data (such as
data elements, data sets, and
databases).
2. Ensure that documentation in
the health record supports the
diagnosis and reflects the
patient’s progress, clinical
findings, and discharge status.
16 Column 1 -­‐ HIM Baccalaureate Degree Entry-­‐Level Competencies (Student Learning Outcomes) Column 2 -­‐ Knowledge Clusters (Curricular Components) •
I.B. Subdomain: Healthcare Information Requirements and Standards 1. Develop organization-­‐wide health record documentation guidelines. 2. Maintain organizational compliance with regulations and standards. 3. Ensure organizational survey readiness for accreditation, licensing and/or certification processes. 4. Design and implement clinical documentation initiatives. I.C. Subdomain: Clinical Classification Systems 1. Select electronic applications (Evaluating, 5) Data capture tools and technologies (such as forms; data input screens; templates, other health record documentation tools) (Evaluating, 5) Healthcare Information Requirements and Standards • Standards and regulations for documentation (such as Joint Commission, CARF, COP) (Evaluating, 5) • Health information standards (such as HIPAA, ANSI, HL-­‐7, UMLS, ASTM ) (Applying, 3) •
Patient Identity Management Policies (MPI) (Applying, 3) Clinical Classification Systems • Healthcare taxonomies, clinical vocabularies, nomenclatures (such as ICD-­‐9-­‐CM, ICD-­‐10-­‐
Column 3 – For each Knowledge Cluster (curriculum component) state the course # HIA321 HIA321 HIA321 HIA321 HIA 405 17 Column 1 -­‐ HIM Baccalaureate Degree Entry-­‐Level Competencies (Student Learning Outcomes) Column 2 -­‐ Knowledge Clusters (Curricular Components) for clinical classification and coding. 2. Implement and manage applications and processes for clinical classification and coding. •
3. Maintain processes, policies, and procedures to ensure the accuracy of coded data. •
•
I.D. Subdomain: Reimbursement Methodologies 1. Manage the use of clinical data required in prospective payment systems (PPS) in healthcare delivery. 2. Manage the use of clinical data required in other reimbursement systems in healthcare delivery. 3. Participate in selection and development of applications and processes for chargemaster and claims management. 4. Implement and manage processes for compliance and reporting. 5. Participate in revenue cycle management. CM/PCS, CPT, SNOMED-­‐CT, DSM-­‐IV, LOINC) (Understanding, 2) Severity of illness systems (Analyzing, 4) Data integrity, coding audits (Analyzing, 4) CCI, electronic billing, X12N, 5010 (Applying, 3) Reimbursement Methodologies •
•
•
•
Clinical data and reimbursement management (Evaluating, 5) Compliance strategies and reporting (Analyzing, 4) Chargemaster management (Analyzing, 4) Case mix management (Analyzing, 4) Column 3 – For each Knowledge Cluster (curriculum component) state the course # HIA 405 HIA 405 HIA 406 HIA 407: HIA 408 HIA 407 HIA 408 HIA 408 HIA 408 HIA 406 HIA 408 HIA 408 18 Column 1 -­‐ HIM Baccalaureate Degree Entry-­‐Level Competencies (Student Learning Outcomes) II. Domain: Health Statistics,
Biomedical Research, and Quality
Management
II.A. Subdomain: Healthcare Statistics and Research Column 2 -­‐ Knowledge Clusters (Curricular Components) Column 3 – For each Knowledge Cluster (curriculum component) state the course # Audit process such as compliance and reimbursement (Evaluating, 5) •
HIA 407: Research and compare two • Payment systems (such as different payer PPS, DRGs, APCs, RBRVS, RUGs, MSDRGs) (Analyzing, insurance plans (federal, 4) commercial, • Commercial, managed care, managed care) and federal insurance plans to determine benefits, costs, (Analyzing, 4) and services. • Revenue cycle process HIA 407: (Analyzing, 4) Exercise to calculate payment for a variety of patient services based on payer methodologies. HIA 407 HIA 407 HIA 408 Healthcare Statistics and Research HIA333 • Statistical analysis on healthcare data (Applying, 3) • Descriptive statistics (such as means, standard deviations, HIA333 19 Column 1 -­‐ HIM Baccalaureate Degree Entry-­‐Level Competencies (Student Learning Outcomes) 1. Analyze and present data for quality management, utilization management, risk management, and other patient care related studies. 2. Utilize statistical software. 3. Ensure adherence to Institutional Review Board (IRB) processes and policies. Column 2 -­‐ Knowledge Clusters (Curricular Components) •
•
•
•
•
•
•
•
•
frequencies, ranges, percentiles) (Analyzing, 4) Inferential statistics (such as t-­‐tests, ANOVAs, regression analysis, reliability, validity) (Applying, 3) Vital statistics (Applying, 3) Epidemiology (Understanding, 2) Data reporting and presentation techniques (Evaluating, 5) Computerized statistical packages (Understanding, 2) Research design/methods (such as quantitative, qualitative, evaluative, outcomes) (Applying, 3) Knowledge-­‐based research techniques (such as Medline, CMS, libraries, web sites) (Applying, 3) National guidelines regarding human subjects’ research (Analyzing, 4) Institutional review board process (Understanding, 2) Column 3 – For each Knowledge Cluster (curriculum component) state the course # HIA333 HIA333 HIA333 HIA333 HIA333 HIA333 HIA 321: Research clinical trials in your state. Choose one and summarize key points. Asmt 7.1 HIA333: Create a table comparing indicators for quality patient outcomes 20 Column 1 -­‐ HIM Baccalaureate Degree Entry-­‐Level Competencies (Student Learning Outcomes) Column 2 -­‐ Knowledge Clusters (Curricular Components) •
II.B. Subdomain: Quality Management and Performance Improvement 1. Provide support for facility-­‐wide quality management and performance improvement programs. 2. Analyze clinical data to identify trends that demonstrate quality, safety, and effectiveness of healthcare. Research protocol data management Understanding, 2) Quality Management and Performance Improvement • Quality assessment, and management tools (such as benchmarking, Statistical Quality Control, and Risk Management) (Analyzing, 4) • Utilization and resource management (Analyzing, 4) Column 3 – For each Knowledge Cluster (curriculum component) state the course # based on research. Asmt 5.2 HIA333: Analyze the role of the IRB in human subjects’ research and discuss the ethical issues encountered in this type of research. DQ 5.1 HIA333: Discuss the role of the IRB in healthcare HIA333 HIA333 HIA333 21 Column 1 -­‐ HIM Baccalaureate Degree Entry-­‐Level Competencies (Student Learning Outcomes) Column 2 -­‐ Knowledge Clusters (Curricular Components) 3. Apply Quality Management tools. •
•
•
•
III. Domain: Health Services Organization and Delivery III.A. Subdomain: Healthcare Delivery Systems 1. Evaluate and implement national health information initiatives in the healthcare delivery system for application to information systems policies and procedures. 2. Interpret, communicate, and apply current laws, accreditation, Disease management process (such as case management, critical paths) (Analyzing, 4) Outcomes measurement (such as patient, customer satisfaction, disease specific) (Evaluating, 5) Benchmarking techniques (Creating, 6) Patient and organization safety initiatives (Applying, 3) Healthcare Delivery Systems •
•
•
Column 3 – For each Knowledge Cluster (curriculum component) state the course # HIA333 HIA333 HIA333 HIA333 Organization and delivery of HIA321 healthcare systems (Evaluating, 5) HIA321 Components and operation of healthcare organizations including e-­‐health delivery (Evaluating, 5) HIA 321 Accreditation standards (such as Joint Commission, NCQA, CARF, CHAP, URAC) (Evaluating, 5) HIA322 22 Column 1 -­‐ HIM Baccalaureate Degree Entry-­‐Level Competencies (Student Learning Outcomes) licensure and certification standards related to health information initiatives at the national, state, local, and facility levels. 3. Analyze and respond to the information needs of internal and external customers throughout the continuum of healthcare services. 4. Revise policies and procedures to comply with the changing health information regulations. 5. Translate and interpret health information for consumers and their caregivers. III.B. Subdomain: Healthcare Privacy, Confidentiality, Legal, and Ethical Issues 1. Coordinate the implementation of legal and regulatory requirements related to the health information infrastructure. 2. Manage access and disclosure of personal health information. 3. Develop and implement organization-­‐wide confidentiality policies and procedures. 4. Develop and implement privacy training programs. Column 2 -­‐ Knowledge Clusters (Curricular Components) Column 3 – For each Knowledge Cluster (curriculum component) state the course # Regulatory and licensure requirements such as COP, state health departments (Evaluating, 5) Federal initiatives: ONC, CCHIT , Red Flag Rules, Meaningful Use (Evaluating, 5) HIA321 Healthcare Privacy, Confidentiality, Legal, and Ethical Issues • Legislative and legal system (Analyzing, 4) HIA322 HIA322 HIA321 HIA322 •
•
•
•
•
Privacy, confidentiality, security principles, policies and procedures (Evaluating, 5) Identity management (Evaluating, 5) Health information laws, regulations, and standards (such as HIPAA, HITECH, 23 Column 1 -­‐ HIM Baccalaureate Degree Entry-­‐Level Competencies (Student Learning Outcomes) Column 2 -­‐ Knowledge Clusters (Curricular Components) 5. Assist in the development of security training. 6. Resolve privacy issues/problems. 7. Apply and promote ethical standards of practice. 8. Define and maintain elements of the legal health record. 9. Establish and maintain e-­‐
Discovery guidelines. IV. Information Technology and Systems IV.A. Subdomain: Information and Communication Technologies 1. Implement and manage use of technology, including hardware and software to ensure data collection, storage, analysis, and reporting of information. 2. Contribute to the development of networks, including intranet and Internet applications to facilitate the electronic health record (EHR), personal health record (PHR), public health, and other administrative applications. 3. Interpret the use of standards to achieve interoperability of healthcare information systems. Joint Commission, State laws) (Evaluating, 5) • Elements of compliance programs (Evaluating, 5) • Professional ethical issues (Evaluating, 5) • Legal Health Record, e-­‐
Discovery guidelinesDiscovery guidelines (Evaluating, 5) • Information security training (Understanding, 2) Information and Communication Technologies • Computer concepts (hardware components, network systems architectures, operating systems and languages, and software packages and tools) (Analyzing, 4) • Communications technologies (networks—
LANS, WANS, WLANS, VPNs) (Understanding, 2) •
•
Data interchange standards (such as NIST, HL7, 5010, Reference Information Modeling (RIM)) (Analyzing, 4) Internet technologies (Intranet, web-­‐based Column 3 – For each Knowledge Cluster (curriculum component) state the course # HIA322 HIA 322 HIA322 HIA322 HIA330 HIA330 HIA 330 HIA330 24 Column 1 -­‐ HIM Baccalaureate Degree Entry-­‐Level Competencies (Student Learning Outcomes) IV.B. Subdomain: Information Systems 1. Apply knowledge of database architecture and design (such as data dictionary, data modeling, data warehousing) to meet organizational needs. 2. Monitor use of clinical vocabularies and terminologies used in the organization’s health information systems. 3. Manage clinical indices/databases/registries. 4. Apply appropriate electronic or imaging technology for data/record storage. Column 2 -­‐ Knowledge Clusters (Curricular Components) systems, standards – SGML, XML) (Analyzing, 4) • Data, information, and file structures (data administration, data definitions, data dictionary, data modeling, data structures, data warehousing, database management systems) (Evaluating, 5) • System interoperability, data sharing, Health Information Exchanges (Evaluating, 5) • Nation-­‐wide Health Information Infrastructure NHIN (Applying, 3) Information Systems • Leading development of health information resources & systems (Analyzing, 4) • Database Architecture and Design (Evaluating, 5) • Human factors and user interface design (Applying, 3) • Systems Development Life Cycle (systems analysis, design, implementation, evaluation, and maintenance) (Evaluating, 5) Column 3 – For each Knowledge Cluster (curriculum component) state the course # HIA321 HIA330 HIA334 HIA330 HIA330 HIA330 HIA330 HIA334 25 Column 1 -­‐ HIM Baccalaureate Degree Entry-­‐Level Competencies (Student Learning Outcomes) Column 2 -­‐ Knowledge Clusters (Curricular Components) 5. Apply knowledge of database querying and data mining techniques to facilitate information retrieval. 6. Implement and manage knowledge-­‐based applications to meet end-­‐user information requirements. 7. Design and generate administrative reports using appropriate software. 8. Apply appropriate electronic or imaging technology for data/record storage. 9. Participate in system selection processes (RFI and RFP). HIA330 HIA334 HIA330: Visit hhs.gov • Regional Health Information website and identify RHIO’s, Exchange (RHIO RHIE?), and the HIE for Health Information each. Evaluate Exchanges (HIE), Regional the benefits of Health Extension Centers the RHIO. Asmt (RHEC) (Evaluating, 5) 2.4 • Project management HIA330 (Evaluating, 5) HIA334 •
10. Evaluate and recommend clinical, administrative, and specialty service applications (RFP vender selection, electronic record, clinical coding). 11. Apply appropriate systems to life cycle concepts, including systems analysis, design, implementation, evaluation, and maintenance to the selection of healthcare information systems. IV.C. Subdomain: Data Security 1. Protect electronic health information through confidentiality Column 3 – For each Knowledge Cluster (curriculum component) state the course # Clinical, business, and specialty systems applications (administrative, clinical decision support systems, electronic health record and computer-­‐based health record systems, nursing, ancillary service systems, patient numbering systemsssystems at master and enterprise levels) (Evaluating, 5) Data Security •
Data security protection methods (such as HIA330 26 Column 1 -­‐ HIM Baccalaureate Degree Entry-­‐Level Competencies (Student Learning Outcomes) and security measures. 2. Protect data integrity and validity using software or hardware technology. 3. Implement and monitor department and organizational data and information system security policies. 4. Recommend elements that must be included in the design of audit trails and data quality monitoring programs. 5. Recommend elements that should be included in the design and implementation of risk assessment, contingency planning, and data recovery procedures. V. Organization and Management V.A. Subdomain: Human Resources Management 1. Manage human resources to facilitate staff recruitment, retention, and supervision. 2. Ensure compliance with employment laws. 3. Develop and implement staff orientation and training programs. 4. Develop productivity standards for health information functions. 5. Monitor staffing levels and productivity, and provide feedback Column 2 -­‐ Knowledge Clusters (Curricular Components) HIA330 Human Resources Management • Employment laws (Analyzing, 4) • Principles of human resources management (recruitment, supervision, retention, counseling, disciplinary action) (Evaluating, 5) • Workforce education and training (Creating, 6) • Performance standards (Evaluating, 5) • Labor trends, market HIA440 HIA440 HIA440 HIA440 HIA440 •
authentication encryption, decryption, firewalls) (Analyzing, 4) Data security (audits, controls, data recovery, e-­‐
security) (Evaluating, 5) Column 3 – For each Knowledge Cluster (curriculum component) state the course # 27 Column 1 -­‐ HIM Baccalaureate Degree Entry-­‐Level Competencies (Student Learning Outcomes) Column 2 -­‐ Knowledge Clusters (Curricular Components) to staff regarding performance. 6. Benchmark staff performance data incorporating labor analytics. 7. Develop, motivate, and support work teams. 8. Analyze and report on budget variances. 9. Evaluate and manage contracts. 10. Apply principles of ergonomics to work areas. V.B. Subdomain: Strategic Planning and Organizational Development 1. Apply general principles of management in the administration of health information services. 2. Assign projects and tasks to appropriate staff. 3. Demonstrate leadership skills. 4. Apply project management techniques to ensure efficient workflow and appropriate outcomes. 5. Facilitate project management by integrating work efforts, as well as planning and executing project tasks and activities. analysis (Analyzing, 4) •
Cost benefit analysis of resource needs (Applying, 3) Strategic Planning and Organizational Development •
•
•
•
•
•
Organizational assessment and benchmarking (Analyzing, 4) Critical thinking skills, emotional intelligence, employee engagement (Analyzing, 4) Project management (Evaluating, 5) Process reengineering and work redesign (Analyzing, 4) Change management (Analyzing, 4) Facilitation of teams and meetings (Applying, 3) Column 3 – For each Knowledge Cluster (curriculum component) state the course # HIA440 HIA333 HIA440 HIA440 HIA334 HIA440 All Courses: Final team projects 28 Column 1 -­‐ HIM Baccalaureate Degree Entry-­‐Level Competencies (Student Learning Outcomes) Column 2 -­‐ Knowledge Clusters (Curricular Components) Column 3 – For each Knowledge Cluster (curriculum component) state the course # Principles of management (Evaluating, 5) require team collaboration •
and project facilitation by all students. • Negotiation techniques (Analyzing, 4) HIA440 • Communication and interpersonal skills (Evaluating, 5) HIA440 • Team/consensus building (Evaluating, 5) HIA440 • Professional development for self and staff (Creating, 6) HIA440 • Problem solving and decision making processes (Evaluating, 5) HIA440 HIA440 Biomedical Sciences Anatomy (Applying, 3) Physiology (Applying, 3) Medical Terminology (Evaluating, 5) Pathophysiology (Analyzing, 4) Pharmacotherapy (Analyzing, 4) 29 Appendix B Bloom’s Taxonomy: Revised Version
1 = Remembering:
Can the student recall or remember the information?
2 = Understanding:
Can the student explain ideas or concepts, and grasp the
meaning of information?
3 = Applying:
Can the student use the information in a new way?
4 = Analyzing:
Can the student distinguish between the different parts,
break down information, and infer to support conclusions?
5 = Evaluating:
Can the student justify a stand or decision, or judge the
value of?
6 = Creating:
Can the student create new product or point of view?
30 Appendix C AHIMA Code of Ethics
American Health Information Management Association
Code of Ethics
Preamble
The ethical obligations of the health information management (HIM) professional include the
safeguarding of privacy and security of health information; disclosure of health information;
development, use, and maintenance of health information systems and health information;
and ensuring the accessibility and integrity of health information.
Healthcare consumers are increasingly concerned about security and the potential loss of
privacy and the inability to control how their personal health information is used and
disclosed. Core health information issues include what information should be collected; how
the information should be handled, who should have access to the information, under what
conditions the information should be disclosed, how the information is retained and when it is
no longer needed, and how is it disposed of in a confidential manner. All of the core health
information issues are performed in compliance with state and federal regulations, and
employer policies and procedures.
Ethical obligations are central to the professional's responsibility, regardless of the
employment site or the method of collection, storage, and security of health information. In
addition, sensitive information (e.g., genetic, adoption, drug, alcohol, sexual, health, and
behavioral information) requires special attention to prevent misuse. In the world of business
and interactions with consumers, expertise in the protection of the information is required.
Purpose of the American Health Information Management Association Code of
Ethics
The HIM professional has an obligation to demonstrate actions that reflect values, ethical
principles, and ethical guidelines. The American Health Information Management Association
(AHIMA) Code of Ethics sets forth these values and principles to guide conduct. (See also
AHIMA Vision, Mission, Values) The code is relevant to all AHIMA members and CCHIIM
credentialed HIM professionals [hereafter referred to as certificants], regardless of their
professional functions, the settings in which they work, or the populations they serve. These
purposes strengthen the HIM professional’s efforts to improve overall quality of healthcare.
The AHIMA Code of Ethics serves seven purposes:
•
•
•
Promotes high standards of HIM practice.
Identifies core values on which the HIM mission is based.
Summarizes broad ethical principles that reflect the profession's core values.
31 •
•
•
•
Establishes a set of ethical principles to be used to guide decision-making and actions.
Establishes a framework for professional behavior and responsibilities when
professional obligations conflict or ethical uncertainties arise.
Provides ethical principles by which the general public can hold the HIM professional
accountable.
Mentors practitioners new to the field to HIM's mission, values, and ethical principles.
The code includes principles and guidelines that are both enforceable and aspirational. The
extent to which each principle is enforceable is a matter of professional judgment to be
exercised by those responsible for reviewing alleged violations of ethical principles.
Code of Ethics Principles
The Code of Ethics and How to Interpret the Code of Ethics
Principles and Guidelines
The following ethical principles are based on the core values of the American Health
Information Management Association and apply to all AHIMA members and certificants.
Guidelines included for each ethical principle are a non-inclusive list of behaviors and
situations that can help to clarify the principle. They are not meant to be a comprehensive
list of all situations that can occur.
I.
Advocate, uphold, and defend the individual's right to privacy and the doctrine of
confidentiality in the use and disclosure of information.
A health information management professional shall:
1.1. Safeguard all confidential patient information to include, but not limited
to, personal, health, financial, genetic, and outcome information.
1.2. Engage in social and political action that supports the protection of privacy
and confidentiality, and be aware of the impact of the political arena on the
health information issues for the healthcare industry.
1.3. Advocate for changes in policy and legislation to ensure protection of
privacy and confidentiality, compliance, and other issues that surface as
advocacy issues and facilitate informed participation by the public on these
issues.
1.4. Protect the confidentiality of all information obtained in the course of
professional service. Disclose only information that is directly relevant or
necessary to achieve the purpose of disclosure. Release information only with
valid authorization from a patient or a person legally authorized to consent on
behalf of a patient or as authorized by federal or state regulations. The
minimum necessary standard is essential when releasing health information for
disclosure activities.
32 1.5. Promote the obligation to respect privacy by respecting confidential
information shared among colleagues, while responding to requests from the
legal profession, the media, or other non-healthcare related individuals, during
presentations or teaching and in situations that could cause harm to persons.
1.6. Respond promptly and appropriately to patient requests to exercise their
privacy rights (e.g., access, amendments, restriction, confidential
communication, etc.). Answer truthfully all patients’ questions concerning their
rights to review and annotate their personal biomedical data and seek to
facilitate patients’ legitimate right to exercise those rights.
II.
Put service and the health and welfare of persons before self-interest and
conduct oneself in the practice of the profession so as to bring honor to oneself,
peers, and to the health information management profession.
A health information management professional shall:
2.1. Act with integrity, behave in a trustworthy manner, elevate service to
others above self-interest, and promote high standards of practice in every
setting.
2.2. Be aware of the profession's mission, values, and ethical principles, and
practice in a manner consistent with them by acting honestly and responsibly.
2.3. Anticipate, clarify, and avoid any conflict of interest, to all parties
concerned, when dealing with consumers, consulting with competitors, in
providing services requiring potentially conflicting roles (for example, finding
out information about one facility that would help a competitor), or serving the
Association in a volunteer capacity. The conflicting roles or responsibilities must
be clarified and appropriate action taken to minimize any conflict of interest.
2.4. Ensure that the working environment is consistent and encourages
compliance with the AHIMA Code of Ethics, taking reasonable steps to eliminate
any conditions in their organizations that violate, interfere with, or discourage
compliance with the code.
2.5. Take responsibility and credit, including authorship credit, only for work
they actually perform or to which they contribute. Honestly acknowledge the
work of and the contributions made by others verbally or written, such as in
publication.
A health information management professional shall not:
2.6. Permit one’s private conduct to interfere with the ability to fulfill one’s
professional responsibilities.
2.7. Take unfair advantage of any professional relationship or exploit others to
further one’s own personal, religious, political, or business interests.
33 III.
Preserve, protect, and secure personal health information in any form or medium
and hold in the highest regards health information and other information of a
confidential nature obtained in an official capacity, taking into account the
applicable statutes and regulations.
A health information management professional shall:
3.1. Safeguard the privacy and security of written and electronic health
information and other sensitive information. Take reasonable steps to ensure
that health information is stored securely and that patients' data is not available
to others who are not authorized to have access. Prevent inappropriate
disclosure of individually identifiable information.
3.2. Take precautions to ensure and maintain the confidentiality of information
transmitted, transferred, or disposed of in the event of termination,
incapacitation, or death of a healthcare provider to other parties through the
use of any media.
3.3. Inform recipients of the limitations and risks associated with providing
services via electronic or social media (e.g., computer, telephone, fax, radio,
and television).
IV.
Refuse to participate in or conceal unethical practices or procedures and report
such practices.
A health information management professional shall:
4.1. Act in a professional and ethical manner at all times.
4.2. Take adequate measures to discourage, prevent, expose, and correct the
unethical conduct of colleagues. If needed, utilize theProfessional Ethics
Committee Policies and Procedures for potential ethics complaints.
4.3. Be knowledgeable about established policies and procedures for handling
concerns about colleagues' unethical behavior. These include policies and
procedures created by AHIMA, licensing and regulatory bodies, employers,
supervisors, agencies, and other professional organizations.
4.4. Seek resolution if there is a belief that a colleague has acted unethically or
if there is a belief of incompetence or impairment by discussing one’s concerns
with the colleague when feasible and when such discussion is likely to be
productive.
4.5. Consult with a colleague when feasible and assist the colleague in taking
remedial action when there is direct knowledge of a health information
management colleague's incompetence or impairment.
34 4.6. Take action through appropriate formal channels, such as contacting an
accreditation or regulatory body and/or the AHIMA Professional Ethics
Committee if needed.
4.7. Cooperate with lawful authorities as appropriate.
A health information management professional shall not:
4.8. Participate in, condone, or be associated with dishonesty, fraud and abuse,
or deception. A non-inclusive list of examples includes:
•
•
•
•
•
•
•
•
•
•
•
•
Allowing patterns of optimizing or minimizing documentation and/or
coding to impact payment
Assigning codes without physician documentation
Coding when documentation does not justify the diagnoses or
procedures that have been billed
Coding an inappropriate level of service
Miscoding to avoid conflict with others
Engaging in negligent coding practices
Hiding or ignoring review outcomes, such as performance data
Failing to report licensure status for a physician through the appropriate
channels
Recording inaccurate data for accreditation purposes
Allowing inappropriate access to genetic, adoption, health, or
behavioral health information
Misusing sensitive information about a competitor
Violating the privacy of individuals
Refer to the AHIMA Standards for Ethical Coding for additional guidance.
4.9. Engage in any relationships with a patient where there is a risk of
exploitation or potential harm to the patient.
V.
Advance health information management knowledge and practice through
continuing education, research, publications, and presentations.
A health information management professional shall:
5.1. Develop and enhance continually professional expertise, knowledge, and
skills (including appropriate education, research, training, consultation, and
supervision). Contribute to the knowledge base of health information
management and share one’s knowledge related to practice, research, and
ethics.
5.2. Base practice decisions on recognized knowledge, including empirically
based knowledge relevant to health information management and health
information management ethics.
35 5.3. Contribute time and professional expertise to activities that promote
respect for the value, integrity, and competence of the health information
management profession. These activities may include teaching, research,
consultation, service, legislative testimony, advocacy, presentations in the
community, and participation in professional organizations.
5.4. Engage in evaluation and research that ensures the confidentiality of
participants and of the data obtained from them by following guidelines
developed for the participants in consultation with appropriate institutional
review boards.
5.5. Report evaluation and research findings accurately and take steps to
correct any errors later found in published data using standard publication
methods.
5.6. Design or conduct evaluation or research that is in conformance with
applicable federal or state laws.
5.7. Take reasonable steps to provide or arrange for continuing education and
staff development, addressing current knowledge and emerging developments
related to health information management practice and ethics.
VI.
Recruit and mentor students, staff, peers, and colleagues to develop and
strengthen professional workforce.
A health information management professional shall:
6.1. Provide directed practice opportunities for students.
6.2. Be a mentor for students, peers, and new health information management
professionals to develop and strengthen skills.
6.3. Be responsible for setting clear, appropriate, and culturally sensitive
boundaries for students, staff, peers, colleagues, and members within
professional organizations.
6.4. Evaluate students' performance in a manner that is fair and respectful when
functioning as educators or clinical internship supervisors.
6.5. Evaluate staff's performance in a manner that is fair and respectful when
functioning in a supervisory capacity.
6.6. Serve an active role in developing HIM faculty or actively recruiting HIM
professionals.
A health information management professional shall not:
36 6.7. Engage in any relationships with a person (e.g. students, staff, peers, or
colleagues) where there is a risk of exploitation or potential harm to that other
person.
VII.
Represent the profession to the public in a positive manner.
A health information management professional shall:
7.1. Be an advocate for the profession in all settings and participate in activities
that promote and explain the mission, values, and principles of the profession to
the public.
VIII.
Perform honorably health information management association responsibilities,
either appointed or elected, and preserve the confidentiality of any privileged
information made known in any official capacity.
A health information management professional shall:
8.1. Perform responsibly all duties as assigned by the professional association
operating within the bylaws and policies and procedures of the association and
any pertinent laws.
8.2. Uphold the decisions made by the association.
8.3. Speak on behalf of the health information management profession and
association, only while serving in the role, accurately representing the official
and authorized positions of the association.
8.4. Disclose any real or perceived conflicts of interest.
8.5. Relinquish association information upon ending appointed or elected
responsibilities.
8.6. Resign from an association position if unable to perform the assigned
responsibilities with competence.
8.7. Avoid lending the prestige of the association to advance or appear to
advance the private interests of others by endorsing any product or service in
return for remuneration. Avoid endorsing products or services of a third party,
for-profit entity that competes with AHIMA products and services. Care should
also be exercised in endorsing any other products and services.
IX.
State truthfully and accurately one’s credentials, professional education, and
experiences.
A health information management professional shall:
9.1. Make clear distinctions between statements made and actions engaged in as
a private individual and as a representative of the health information
37 management profession, a professional health information association, or one’s
employer.
9.2. Claim and ensure that representation to patients, agencies, and the public
of professional qualifications, credentials, education, competence, affiliations,
services provided, training, certification, consultation received, supervised
experience, and other relevant professional experience are accurate.
9.3. Claim only those relevant professional credentials actually possessed and
correct any inaccuracies occurring regarding credentials.
9.4. Report only those continuing education units actually earned for the
recertification cycle and correct any inaccuracies occurring regarding CEUs.
X.
Facilitate interdisciplinary collaboration in situations supporting health
information practice.
A health information management professional shall:
10.1. Participate in and contribute to decisions that affect the well-being of
patients by drawing on the perspectives, values, and experiences of those
involved in decisions related to patients.
10.2. Facilitate interdisciplinary collaboration in situations supporting health
information practice.
10.3. Establish clearly professional and ethical obligations of the
interdisciplinary team as a whole and of its individual members.
10.4. Foster trust among group members and adjust behavior in order to
establish relationships with teams.
XI.
Respect the inherent dignity and worth of every person.
A health information management professional shall:
11.1. Treat each person in a respectful fashion, being mindful of individual
differences and cultural and ethnic diversity.
11.2. Promote the value of self-determination for each individual.
11.3. Value all kinds and classes of people equitably, deal effectively with all
races, cultures, disabilities, ages and genders.
11.4. Ensure all voices are listened to and respected.
38 The Use of the Code
Violation of principles in this code does not automatically imply legal liability or violation of
the law. Such determination can only be made in the context of legal and judicial
proceedings. Alleged violations of the code would be subject to a peer review process. Such
processes are generally separate from legal or administrative procedures and insulated from
legal review or proceedings to allow the profession to counsel and discipline its own members
although in some situations, violations of the code would constitute unlawful conduct subject
to legal process.
Guidelines for ethical and unethical behavior are provided in this code. The terms "shall and
shall not" are used as a basis for setting high standards for behavior. This does not imply that
everyone "shall or shall not" do everything that is listed. This concept is true for the entire
code. If someone does the stated activities, ethical behavior is the standard. The guidelines
are not a comprehensive list. For example, the statement "safeguard all confidential patient
information to include, but not limited to, personal, health, financial, genetic and outcome
information" can also be interpreted as "shall not fail to safeguard all confidential patient
information to include personal, health, financial, genetic, and outcome information."
A code of ethics cannot guarantee ethical behavior. Moreover, a code of ethics cannot resolve
all ethical issues or disputes or capture the richness and complexity involved in striving to
make responsible choices within a moral community. Rather, a code of ethics sets forth
values and ethical principles, and offers ethical guidelines to which a HIM professional can
aspire and by which actions can be judged. Ethical behaviors result from a personal
commitment to engage in ethical practice.
Professional responsibilities often require an individual to move beyond personal values. For
example, an individual might demonstrate behaviors that are based on the values of honesty,
providing service to others, or demonstrating loyalty. In addition to these, professional values
might require promoting confidentiality, facilitating interdisciplinary collaboration, and
refusing to participate or conceal unethical practices. Professional values could require a
more comprehensive set of values than what an individual needs to be an ethical agent in
one’s own personal life.
The AHIMA Code of Ethics is to be used by AHIMA members and certificants, consumers,
agencies, organizations, and bodies (such as licensing and regulatory boards, insurance
providers, courts of law, government agencies, and other professional groups) that choose to
adopt it or use it as a frame of reference. The AHIMA Code of Ethics reflects the commitment
of all to uphold the profession's values and to act ethically. Individuals of good character who
discern moral questions and, in good faith, seek to make reliable ethical judgments, must
apply ethical principles.
The code does not provide a set of rules that prescribe how to act in all situations. Specific
applications of the code must take into account the context in which it is being considered
and the possibility of conflicts among the code's values, principles, and guidelines. Ethical
responsibilities flow from all human relationships, from the personal and familial to the social
and professional. Further, the AHIMA Code of Ethics does not specify which values, principles,
and guidelines are the most important and ought to outweigh others in instances when they
conflict.
39 Code of Ethics 2011 Ethical Principles
Ethical Principles: The following ethical principles are based on the core values of the
American Health Information Management Association and apply to all AHIMA
members and certificants.
A health information management professional shall:
1. Advocate, uphold, and defend the individual's right to privacy and the
doctrine of confidentiality in the use and disclosure of information.
2. Put service and the health and welfare of persons before self-interest and
conduct oneself in the practice of the profession so as to bring honor to
oneself, their peers, and to the health information management
profession.
3. Preserve, protect, and secure personal health information in any form or
medium and hold in the highest regards health information and other
information of a confidential nature obtained in an official capacity,
taking into account the applicable statutes and regulations.
4. Refuse to participate in or conceal unethical practices or procedures and
report such practices.
5. Advance health information management knowledge and practice through
continuing education, research, publications, and presentations.
6. Recruit and mentor students, peers and colleagues to develop and
strengthen professional workforce.
7. Represent the profession to the public in a positive manner.
8. Perform honorably health information management association
responsibilities, either appointed or elected, and preserve the
confidentiality of any privileged information made known in any official
capacity.
9. State truthfully and accurately one’s credentials, professional education,
and experiences.
10. Facilitate interdisciplinary collaboration in situations supporting health
information practice.
11. Respect the inherent dignity and worth of every person.
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_024277.hcsp?dDocName=bok1
_024277
40 Confidentiality Statement and Agreement
All information obtained and learned during the management capstone is completely
confidential. Information obtained from patient medical records is also confidential and
cannot be released without the patient’s written consent.
I understand and agree that as a student in the Health Information Administration Program at
Medaille College, any violation of the confidentiality of patient information may result in
dismissal from the HIM Program as well as possible legal action against me.
___________________________________________
Student Signature
_______________
Date
___________________________________________
Student printed Name
41