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Syllabus

Health Record Applications I
HR100

YEAR:

2023-2024

CREDIT HOURS:

1.00

PREREQUISITES:

None

COREQUISITES:

None

COURSE NOTES:

Student must enroll concurrently in HR103 Introduction to Health Information with this course.

CATALOG COURSE DESCRIPTION:

Lab providing overview of the health information profession; experience in assembly, analysis, and filing of health records; data entry and abstracting of health information; indices; filing of reportable events.

HutchCC INSTITUTION-WIDE OUTCOMES:

  1. Demonstrate the ability to think critically and make reasonable judgments by acquiring, analyzing, combining, and evaluating information.
  2. Demonstrate the skills necessary to access and manipulate information through various technological and traditional methods.
  3. Demonstrate effective communication through reading, writing, listening, and speaking.
  4. Demonstrate effective interpersonal and collaborative skills.
  5. Demonstrate effective quantitative-reasoning and computational skills.

AREA OR PROGRAM OUTCOMES

  1. Demonstrate the Hutchinson Community College institutional outcomes.
  2. Display entry-level knowledge and skills fundamental to the health information management profession.
  3. Demonstrate good communications skills.
  4. Demonstrate skills in technology.
  5. Demonstrate problem-solving and critical-thinking skills.
  6. Comply with AHIMA Code of Ethics and maintain professional conduct.

COURSE OUTCOMES AND COMPETENCIES:

  1. Discover the history of the health record profession and AHIMA.
    1. Trace the origin of the medical record profession and identify important contributors and events.
    2. Explain relationships that exist between/among the AHIMA and state and local health information organizations.
    3. Apply the principles of the Code of Ethics of the American Health Information Management Association (AHIMA) in all professional relationships and in the professional organizations.
    4. State the education requirements for the Health Information Administrator and Health Information Technician.
  2. Explain the organization of health-related facilities.
    1. Summarize the history of the healthcare delivery system.
    2. Differentiate the basic organization of the various types of hospitals and healthcare organizations.
    3. Recognize the impact managed care has had on healthcare providers.
    4. Recognize the impact that external forces have on the healthcare industry.
    5. Identify the various departments in a hospital.
    6. Describe the systems used in reimbursement of healthcare services.
    7. Recognize the role of government in healthcare services.
  3. Explain admission procedures and the master patient index.
    1. Explain the admitting process for an inpatient.
    2. Explain how a medical record is created for a patient.
    3. Explain who is responsible for completing the various portions of the Summary Sheet/Face Sheet and the other names for this form.
    4. Explain the impact of inaccurate admitting information.
    5. Complete demographic information in the medical record obtained from the patient at admission to an acute care facility.
    6. Identify common departments that would be found in a primary facility and define their purpose.
    7. Use software to access a master patient index and create files on fictitious patients.
  4. Assemble and analyze records.
    1. Identify media used in health information - paper, computer.
    2. Identify major chart forms, their composition, and be able to assign responsibility for completion of each.
    3. Ascertain the content of health records in healthcare settings.
    4. Follow procedures to compile primary health records, including medical/surgical, obstetrical, and newborn charts.
    5. Follow and apply existing procedures for quantitative analysis of medical/surgical, obstetrical, newborn and outpatient/emergency records.
    6. Perform qualitative analysis on records to ensure that documentation supports the diagnosis and reflects the patient's progress, clinical findings and discharge status.
    7. Use software to access a chart deficiency system and create and update files on fictitious patients.
    8. Identify TJC requirements regarding documentation requirements.
  5. Create birth, death, and fetal death certificates.
    1. Define live birth and fetal death.
    2. Explain when a birth certificate is completed and when a fetal death certificate is completed.
    3. Demonstrate the ability to determine which surname can be legally given to a child based on given situations.
    4. Demonstrate the ability to determine the location of a child's birth based on given situations.
    5. Explain the difference between the attendant at an infant's birth and the person certifying the birth.
    6. Define Apgar score and list the areas evaluated when determining an Apgar score for an infant.
    7. Explain the two major portions of the birth and fetal death certificate forms.
    8. Explain the filing process and requirements with your state's Department of Health for paper certificates and electronic certificates.
    9. Demonstrate the ability to accurately complete birth and fetal death certificates based on given circumstances.
    10. Explain the process and responsibility for completion of death certificates in your state.
    11. Explain the completion of the cause of death and contributing factors on a death certificate.
    12. Explain the uses of the data gathered in completion of birth, death, and fetal death certificates, and induced termination of pregnancy reports.
  6. Organize and manage patient files.
    1. Explain the different numbering and filing systems.
    2. Accurately file charts and in terminal digit, straight numeric and alphabetical order.
    3. Accurately complete sequences of medical record numbers for filing.
    4. Follow and apply existing policies and procedures to retrieve and file charts with active and inactive record files.
    5. Describe various health record storage systems.
    6. Discuss various tools used to control the location of records.
    7. Describe the maintenance and monitoring of data storage systems.
  7. Use abstracts and indices.
    1. Discuss different secondary data sources.
    2. Define index and list the major purpose of an index.
    3. Define simple indexing and cross-indexing.
    4. List and describe the routine data elements found in the following indices: disease, operation, and physician.
    5. Use disease, operation, and physician indices to gather data and generate information.

COURSE ASSESSMENT AND EVALUATION:

1. Assignments 2. Quizzes 3. Participation

ACCOMMODATIONS STATEMENT:

Any student who has a documented disability and wishes to access academic accommodations (per the 1973 Rehabilitation Act and Americans with Disability Act) must contact the HCC Coordinator of Disability Services, at 620-665-3554, or the Student Success Center, Parker Student Union. The student must have appropriate documentation on file before accommodations can be provided.

ACADEMIC HONESTY:

Education requires integrity and respect for HutchCC's institutional values. HutchCC students are required to maintain honesty through a "responsible acquisition, discovery, and application of knowledge" in all academic pursuits. Preserving and upholding academic honesty is the responsibility of Hut chCC students, faculty, administrators and staff.

I. Student Responsibilities

All HutchCC students are required to:

  • Submit all work in all courses without cheating, fabrication, plagiarism, dissimulation, forgery, sabotage, or academic dishonesty as defined below.
  • Provide all academic records such as transcripts and test scores that are free of forgery.
  • Refrain from participating in the academic dishonesty of any person.
  • Use only authorized notes and student aids.
  • Use technology appropriately, including refraining from submitting AI (Artificial Intelligence)-generated work without express written consent from your instructor.
  • Protect the security of passwords/login/privacy/electronic files, and maintain sole individual access for any online course information.

II. Definition of Academic Dishonesty

  • Academic dishonesty is any intentional act, or attempted act, of cheating, fabrication, plagiarism, dissimulation, forgery, or sabotage in academic work.
  • Cheating includes using unauthorized materials of any kind, whether hard copies, online, or electronic, such as unapproved study aids in any academic work, copying another student's work, using an unauthorized "cheat sheet" or device, or purchasing or acquiring an essay online or from another student.
  • Fabrica tion is the invention or falsification of any information or citation in any academic work, such as making up a source, providing an incorrect citation, or misquoting a source.
  • Plagiarism is the representation of words, ideas and other works that are not the student's own as being original to the student. A no n-inclusive list of examples includes work completed by someone else, work generated by an external entity (such as AI), omitting a citation for work used from another source, or borrowing the sequence of ideas, arrangement of material, and/or pattern of thought of work not produced by the student, even though it may be expressed in the student's own words.
  • Dissimulation is the obscuring of a student's own actions with the intention of deceiving others in any academic work, such as fabricating excuses for absences or missed assignments, or feigning attendance.
  • Forgery of academic documents is the unauthorized altering, falsification, misrepresentation, or construction of any academic document, such as changing transcripts, changing grades on papers or on exams which have been returned, forging signatures, manipulating a digital file of academic work, or plagiarizing a translation.
  • Sabotage is any obstruction or attempted obstruction of the academic work of another student, such as impersonating another student, stealing or ruining another student's academic work.
  • Aiding and abetting academic dishonesty is considered as knowingly facilitating any act defined above.
  • Academic honesty violations can also include the omission or falsification of any information on an application for any HutchCC academic program.

III. Sanctions for Academic Dishonesty

Students who violate the Academic Honesty Policy may be subject to academic or administrative consequences.

Instructor Sanctions for Violation:

Students suspected of violating the Academic Honesty Policy may be charged in writing by their instructor and any of the following may apply:

  • Assign Avoiding Plagiarism Bridge Module
  • Receiving written warning that could lead to more severe sanction if a second offense occurs
  • Revising the assignment/work in question for partial credit
  • Voiding work in question without opportunity for make-up
  • Reducing the grade for work in question
  • Lowering the final course grade
  • Failing the work in question

Institutional Sanctions for Violation:

Students charged with academic dishonesty, particularly in instances of repeated violations, may further be subjected to an investigation and any of the following may apply:

  • Instructor recommendation to the Vice President of Academic Affairs (VPAA) to dismiss the student from the course in which the dishonesty occurs
  • Instructor recommendation to the VPAA to dismiss student from the course in which the dishonesty occurs with a grade of 'F." Student will not be allowed to take a 'W' for the course
  • Instructor recommendation to the VPAA that the student be suspended and/or dismissed from the program
  • Student barred from course/program for a set period of time or permanently
  • May be recommended by the instructor (after documented repeated offenses) to the VP AA that the student be placed on probation, suspended and/or dismissed from the institution.

IV. Procedure

  • Instructor will communicate in writing via the student's HutchCC email account and/or LearningZone email account to the student suspected of violating the Academic Honesty Policy.  That communication may include sanction(s). Department Chair will notify the student's academic advisor upon receipt of the Academic Honesty Violation Form.
  • For each violation, the instructor will submit a completed Academic Honesty Violation Form to the Department Chair. Department Chair will notify the student's academic advisor upon receipt of the Academic Honesty Violation form.
  • Should the instructor choose to pursue institutional sanctions, the instruct or shall notify the student in writing via the student's HutchCC email account.  Instructor shall also submit a completed Academic Honesty Violation Form and all prior completed forms regarding said student to the Department Chair and the office of the VPAA with recommendation to proceed with specific Institutional Sanctions. Department Chair will notify the student's academic advisor upon receipt of the Academic Honesty Violation Form.
  • The decision of the VPAA on Institutional Sanction is final. The VPAA will notify the student's academic advisor of any institutional sanctions.

V. Due Process Rights

Students charged with violations of academic honesty have the right of appeal and are assured of due process through the Academic Honesty Appeal process.

Academic Honesty Appeal Process

I. Due Process Rights: Students charged with violations of academic honesty have the right of appeal and are assured of due process through the Academic Honesty Appeal process.

  • If an instructor has recommended course or program dismissal, the student may continue in coursework (provi ding there are no threatening or security behavioral issues) until appeal processes are concluded. However, if an issue has been documented at a partnership location (e.g., clinical sites, secondary institutions, correctional or military facilities), then the student is no longer eligible to continue participation in internships, apprenticeships, and/or clinical-based practice. For clinical sites, this sanction is immediate.

II. Process

If the student disagrees with the charge of a violation of academic honesty, the student has the right to due process as described in the Academic Honesty Appeal process below:

  • If the matter is not resolved upon communicating with the instructor about the violation, the student shall, within five business days of the issuance of the written notice of violation, submit a completed Academic Honesty Appeal Form and supporting documentation to the appropriate department chairperson to initiate an Academic Honesty Appeal.
  • Within two business days of receiving the student's completed Academic Honesty Appeal Form, the Department Chair and VPAA will review and the VPAA will render a decision.
  • Within two business days, a response will be sent to the student's HutchCC email address. The VPAA's decision is final.

INCOMPLETE GRADE:

Instructors may give a student a grade of Incomplete (I) under the following conditions:

  1. The student must initiate the request prior to the time final course grades are submitted to Records.
  2. The request must be made because of an emergency, illness or otherwise unavoidable life-event.
  3. The instructor must agree to the request before a grade of Incomplete can be submitted.
  4. A written contract between the instructor and student, signed by both, will document the work required and date needed to complete course work.
  5. If a student does not complete the course requirements within the time frame established by the instructor, a grade of "F" will be recorded on the student's transcript at the end of the next semester.

PROGRAM ACCREDITATION:

Commission on the Accreditation for Health Informatics and Information Management Education (CAHIIM)
233 N. Michigan Ave, 21st Floor
Chicago, IL 60601-5800

HLC ACCREDITATION:

Hutchinson Community College is accredited by the Higher Learning Commission (HLC). The Higher Learning Commission is one of six regional institutional accreditors recognized by the US Department of Education and the Council on Higher Education Accreditation (CHEA).

Last Revised: 03/19/2020