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Official Course
Description: MCCCD Approval: 12-13-05 |
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HIM105
2006 Fall – 2009 Fall |
LEC |
1.0 Credit(s) |
1.0 Period(s) |
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Health
Record Documentation for Allied Health Professionals |
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Introduction
to health record content, structure, and origin of clinical information for
various healthcare settings. A basic review of federal, state, and
organizational documentation guidelines. Legal and ethical issues applicable
to health information documentation and coding practices. Prerequisites: HCC130 or permission of
Program Director. |
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Go to Competencies Go to Outline
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MCCCD
Official Course Competencies: |
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HIM105 2006
Fall – 2009 Fall |
Health Record Documentation for Allied Health
Professionals |
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1.
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Identify the various types, uses, users, and formats of
health records. (I) |
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2.
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Describe the content of health records in various
healthcare settings. (II, III) |
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3.
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Identify key documents and documentation in health
records. (III) |
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4.
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Describe documentation guidelines used to ensure proper
healthcare documentation. (III) |
Go to Description Go to top of
Competencies
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MCCCD
Official Course Outline: |
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HIM105 2006
Fall – 2009 Fall |
Health Record Documentation for Allied Health
Professionals |
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I. Health Records A. Definition B. History and development C. Purpose, uses, and users
1. Internal 2. External D. Formats 1. Paper-based 2. Electronic 3. Hybrid II. Types of Health Records
A. Hospital B. Ambulatory C. Long-term care D. Other healthcare
settings III. Health Records and
Documentation A. Key components and
origin 1. Medical history 2. Physical exam 3. Physician orders 4. Discharge summary 5. Consultation reports 6. Operative reports 7. Ancillary records 8. Other components B. Documentation guidelines
1. Internal and external 2. Professional standards |