HIM 477: Mastering Documentation

Course Description

In this course, students will practice defining and applying documentation standards and learn how to communicate, interact, and engage providers in the standards of documentation as an integral part of the practice of medicine. Coding standards will be reviewed, along with the relationship to quality documentation

(3 credits)

Prerequisites

  • BIO 212: Anatomy and Physiology
  • BIO 215: Pathophysiology
  • HCA 105: Medical Terminology
  • HIM 205: Reimbursement Methodologies
  • HIM 210: Clinical Classification Systems 1
  • HIM 211: Clinical Classification Systems 2
  • HIM 371: Revenue Cycle and CDI*
  • HIM 373: CDI Operational Process*

* May be taken concurrently.

Program Learning Outcomes (PLOs)

Students who graduate with a major in Health Information Management will be able to:

  1. Demonstrate an understanding of the different fields of medical science, information technology, and business management applicable in health information management.
  2. Demonstrate a fundamental knowledge of facts, terms, and concepts important to the processing of health information.
  3. Apply information acquisition skills to the processing, maintenance, and security of health information.
  4. Demonstrate an ability to do the coding and billing important in the processing of health information.
  5. Understand database information technology and apply it to modern electronic medical records management.
  6. Understand and use quantitative and qualitative research methodologies in health information management.
  7. Demonstrate an understanding of the importance of maintaining quality management techniques in health information management.
  8. Demonstrate an understanding of the importance of the maintenance of staff development in health information management.
  9. Understand and use project management techniques and their application to modern business management.

Student Learning Outcomes (SLOs)

Upon successful completion of the course, the student will be able to:

  1. Apply documentation standards to medical records.
  2. Investigate communication techniques to interact with providers.
  3. Implement appropriate coding standards for clinical documentation integrity.
  4. Analyze medical records to ensure diagnoses and procedures are coded to the highest level of specificity.
  5. Compose compliant queries that are clinically relevant for a given diagnosis or procedure.

Course Activities and Grading

AssignmentsWeight

Discussions (320 points, Weeks 1-8)

32%

Quizzes (150 points, Weeks 2-7)

15%

Oral Presentation, Parts 1- 7 (280 points Weeks 1-7)

28%

Final Presentation (250 points, Week 8)

25%

Total

100%

Required Textbooks

Available through Charter Oak State College's online bookstore

  • Hess, P.C. Clinical Documentation Improvement: Principles and Practice. AHIMA, 2015. ISBN-13:  978-1-58426-502-3

Additional Required Materials

Course Schedule

Week

PLOS

SLOs

Readings and Exercises

Assignments

1

5

1,2

Topics:  Impact of CDI in all Healthcare Settings

  • Reading:
    • Clinical Documentation Improvement: Principles and Practice, Chapter 18, Growing the Clinical Documentation Improvement Program in All Patient-Care Areas (pp. 297-309)
  • Review course syllabus
  • Review course policies
  • Read assigned chapter
  • Post Introduction Discussion (not graded)
  • Participate in Discussions – Case Study
  • Submit Week 1 Assignment

2

1,2

1,3,4,5

Topic: Analyzing the Medical Record

  • Reading:
    • Clinical Documentation Improvement: Principles and Practice, Chapter 5, Assessing Clinical Documentation (pp. 75-99)
  • Read assigned materials
  • Review lecture material
  • Participate in discussions
  • Submit Week 2 Assignment
  • Complete Week 2 Quiz

3

1,2

1,3,4,5

Topic: Mastering Outpatient CDI

  • Reading:
    • Outpatient Clinical Documentation Improvement (CDI) Toolkit (pp. 6-11 & 17-22)
  • Read assigned materials
  • Review lecture material
  • Participate in discussions
  • Submit Week 3 Assignment
  • Complete Week 3 Quiz

4

1,2

1,3,4,5

Topic: Mastering Inpatient CDI

  • Readings:
    • Inpatient Query Toolkit
    • Components of an Effective Inpatient Coding Compliance Program
  • Read assigned materials
  • Review lecture material
  • Participate in discussions
  • Submit Week 4 Assignment
  • Complete Week 4 Quiz

5

3,6,8

1,2,4,5

Topic: Embed Queries in the Medical Record

  • Reading:
    • Clinical Documentation Improvement: Principles and Practice, Chapter 10, Documentation Review and Physician Queries (pp. 171-184)
  • Read assigned materials
  • Review lecture material
  • Participate in discussions
  • Submit Week 5 Assignment
  • Complete Week 5 Quiz

6

5,6

2,5

Topic: Incorporating Technology in CDI Programs

  • Readings:
    • Clinical Documentation Improvement: Principles and Practice, Chapter 15, Synergies with the Electronic Health Record (pp. 257-269)
    • Clinical Documentation Improvement: Principles and Practice, Chapter 16, Clinical Documentation Improvement Technology (pp. 273-282)
  • Read assigned materials
  • Review lecture material
  • Participate in discussions
  • Submit Week 6 Assignment
  • Complete Week 6 Quiz

7

3,6,8

2,5

Topic: Power of Effective Communication and Critical Thinking Skills

  • Readings:
    • Clinical Documentation Improvement: Principles and Practice, Chapter 19, Critical Thinking (pp. 311-323)
  • Read assigned materials
  • Watch Video
  • Review lecture material
  • Participate in discussions
  • Submit Week 7 Assignment
  • Complete Week 7 Quiz
 81,2,4,6,812,3,4

Topic: Design Effective Provider/Non-Provider Training

  • Reading:
    • Clinical Documentation Improvement: Principles and Practice, Chapter 8, Physician Training (pp. 143-153)
    • Clinical Documentation Improvement: Principles and Practice, Chapter 9, Training Nonphysician Clinicians and CDI Program Staff (pp. 157-168)
  • Read assigned materials
  • Review lecture material
  • Participate in discussions
  • Submit Final Project
  • Complete Course Evaluation

COSC Accessibility Statement

Charter Oak State College encourages students with disabilities, including non-visible disabilities such as chronic diseases, learning disabilities, head injury, attention deficit/hyperactive disorder, or psychiatric disabilities, to discuss appropriate accommodations with the Office of Accessibility Services at OAS@charteroak.edu.

COSC Policies, Course Policies, Academic Support Services and Resources

Students are responsible for knowing all Charter Oak State College (COSC) institutional policies, course-specific policies, procedures, and available academic support services and resources. Please see COSC Policies for COSC institutional policies, and see also specific policies related to this course. See COSC Resources for information regarding available academic support services and resources.