HIM 103 - Health Care Documentation
Introduction to the development, form, content, and evaluation of the health record. Introduction to hospital admitting department. Introduction to the organization, responsibilities, and committees of the hospital medical staff. Health record principles are applied in the laboratory setting.
Prerequisite: HIM 100 with a grade of C or better.
Course Learning Outcomes
1. Analyze the documentation in the acute care health records to ensure support for the diagnosis, which might include the patient’s progress, clinical findings or discharge information.
2. Verify the documentation in the health record is timely, complete, and accurate.
3. Identify a complete acute care health record according to organizational policies, external regulations, or standards.
4. Differentiate the roles and responsibilities of various providers/allied health personnel to support documentation requirements throughout the continuum of health care.
5. Apply policies and procedures to ensure the accuracy/integrity of health data.
6. Maintain health data to fulfill health information needs.
7. Identify the use of legal documents.
8. Adhere to the legal and regulatory requirements related to health information management.
Course Offered Fall