College of Public Health Department of Health Information

College of Public Health

Department of Health Information Management and

Technology (HIMT)

INTERNSHIP TRAINING MANUAL

2017/1438

Prepared by:

HIMT Department

HIMT Internship Training Manual, 2015/1436 1

TABLE OF CONTENTS

HIMT Program Description ...................................................................................... 2

Introduction ................................................................................................... 2

Professional Aims ......................................................................................... 2

Curriculum and program learning outcomes................................................. 3

General Rules and Regulations ................................................................................. 4

General Rules and Regulations (Arabic) .................................................................. 9

Internship Program Description ................................................................................ 13

Introduction ................................................................................................... 13

Professional Aims ......................................................................................... 13

Internship Centers ..................................................................................................... 16

Internship Reporting.................................................................................................. 15

Appendices ................................................................................................................

Confidentiality Statement Form .................................................................... 17

Leave Form ................................................................................................... 18

Attendance Form ........................................................................................... 19

Evaluation Form 20

Contacts of Training Affairs Numbers .......................................................... 21

Reporting Form ............................................................................................. 22

Appendix 1: List of Basic and Advanced Tasks for Each Rotation .............. 23


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Introduction:

Health Information Management and Technology (HIMT) is concerned

with planning, collecting, storage, retrieval, and dissemination of health

information towards providing quality health services. Along with the advances and

innovations taking place around the world in all disciplines especially in the field of

Information Technology, arises the need for highly qualified personnel in the field

of Health Information Management and Technology. The Department of HIMT is

in the College of Public Health. The mission, vision and values of the college are

given in the insert below.

College of Public Health.

Department of Health Information Management and Technology

Vision, Mission & Values of the College of Public Health Vision: A leading college in public health education, research and community services, locally, regionally and internationally. Mission: Providing a high quality professional experience focusing on education, research and community service in public health Values: Respect, Diversity, Teamwork and collaboration, Innovation,

Professionalism and Social responsibility


Professional Aims:

The HIMT Program aims at graduating technical and executive experts able to:

1- Plan, implement, and evaluate information systems towards full integration

between traditional and new information systems.

2- Manage health information through: Storage and retrieval of medical data;

qualitative and quantitative analysis of medical records; using international

standard coding of diseases; design medical formats and indices manually or

computerized; and design statistical report formats.

3- Assist in designing efficient Health Information Systems (HISs) at health

facilities by planning and implementing: Objectives for HISs; policies

for HISs; procedures for quality HISs; internal and external coordination

between health organizations; human and non-human resources for HISs;

security plans for HISs; and emergency plans for HISs.

4- Coordinate with the health team to: Achieve criteria for valid and

reliable health information; achieve maximum gain from computer

applications for managerial and clinical aspects; undergo health systems

research; and train the health team for the utilization of health systems.

Curriculum and program learning outcomes:

The bachelor degree in Health Information Management and Technology is

based on 4-year program totalling 131 credit units for females (and later 132 credit

units for males) . The first two semesters cover general education requirement. The

remaining six semesters cover multidisciplinary courses in the areas of Health

Information Management, Healthcare Management, Health Information

Technology, Computer Science, and Basic Medical Sciences. In addition, practical

professional experience is carried out in King Fahd University Hospital among

others. The fifth year of the program is an Internship training year carried out in

several hospitals. The four-year Curriculum is shown below, followed by the

program learning outcomes.


Curriculum, HIMT program

FIRST YEAR – FIRST SEMESTER FIRST YEAR – SECOND SEMESTER

Course Title Course Code

Credit Hours


Credit Hours

English Language ENGL 101

5 English Language ENGL 101

5

Mathematics(1) MATH

111 3 Mathematics(2)

MATH 112

2

Computer Skills COMP

131 2 Physics PHYS 132 3

Learning and Searching Skills

LRSK 141

2 Communication

Skills CMSK142 2

Total 12 Total 16

SECOND YEAR – FIRST SEMESTER SECOND YEAR – SECOND SEMESTER


Credit Hours


Credit Hours

The Economic System Islam

ISLM 251

2 Political System in

Islam ISLM 252 2

Basic Biostatistics HIMT 211

2 System Analysis and

Design-I HIMT

221 3

Principles of Health Care Management

HIMT 212

3 Health Data Content and

Structure

HIMT 223

4

Computer fundamentals in

Health care

HIMT 213

4 Introductory Epidemiology

HIMT 224

2

Intro To HIMT HIMT

214 2

Healthcare Database

Administration

HIMT 225

3

Introduction to Anatomy

ANAT 215

3 Behavioral Science PSYCO

226 2

Medical Terminology

HIMT-216

3

Total 19 Total 16


Curriculum (cont’d), HIMT program

THIRD YEAR – FIRST SEMESTER THIRD YEAR – SECOND SEMESTER


Credit Hours


Credit Hours

Health Data Classification and Coding System – I

HIMT 311

4 Health Data

Classification and Coding System – II

HIMT 321

4

System Analysis and Design-II

HIMT 314

2 Health info.

Management in Acute Care

HIMT 325

3

Health Care Delivery System

HIMT 315

2 Professional

Practice Experience- I

HIMT 326

2

Fundamentals of Human Diseases –I

HIMT 316

2 Quality

Improvement in Health Care

HIMT 327

3

Intro. To Health Information Applications

HIMT 317

4 Fundamentals of

Human Diseases – II HIMT 328

3

Healthcare Database

Administration II

HIMT 318

2 Electronic Health

Records HIMT 329

3

Total 16 Total 18

FOURTH YEAR – FIRST SEMESTER FOURTH YEAR – SECOND SEMESTER


Credit Hours


Credit Hours

Research Methodology

HIMT 411

3 Professional Code

of Ethics HIMT 421

1

Health info. Management in non

Acute Care

HIMT 413

3 Graduation Project HIMT 424

6

Legal Aspects and Ethics of Health

Information

HIMT 414

2 Human Resource

Management HIMT425 2

Analytical Biostatistics

HIMT 415

3 Financial

Management HIMT 427

2

Professional Practice Experience

- II

HIMT 417

4 Reimbursement Methodologies

HIMT 428

2

Health Economics HIMT 418

3 Computer Networks HIMT 429

3

Total 18 Total 16

Total number of credit hours= 131


HIMT Program Student Learning Outcomes

Program Student Learning Outcomes

1. Knowledge

1.1 Identify Different theories, techniques and practices related to healthcare

management & quality, health information management, health informatics, and

research.

1.2 Recognize privacy, confidentiality and security of health information as well as

legal and ethical issues in healthcare.

1.3 Describe Methodology & bio-statistical tools in healthcare

2. Cognitive

2.1 Evaluate the implementation and utilization of HIS for healthcare improvement.

2.2 Utilize technology for data collection, storage, analysis and reporting of

information.

2.3 Carry out valid research study in a healthcare setting.

2.4 Use of relevant software to obtain selected HIM outcomes

2.5 Solve complex healthcare issues by utilizing relevant tools, theories, and evidence

based practice.

2.6 Interpret health data from different sources

2.7 Apply disease and procedure codes using international classification systems.

2.8 Compare local and international healthcare delivery and financial systems

3. Interpersonal Skills and Responsibility

3.1 Demonstrate the importance of working in teams

3.2 Demonstrate professionalism and work ethics.

3.3 Apply creative thinking skills

4. Communication, information technology and numerical skills

4.1 Demonstrate excellent oral communication skills.

4.2 Demonstrate excellent academic writing skills.


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1. Internship Training Administrative Structure

Internship training is directed and supervised by the Dean of the College

2. Admission Requirements

2.1 To be admitted to the College of Public Health Internship training

program, the intern must be a graduate of the Imam AbdulRahman Bin

Faisal University and one who has satisfied all the graduation

requirements, and graduation has been approved by the Faculty Board.

2.2 Graduates from other recognized Allied Medical Sciences/Public Health

Colleges may be accepted upon approval from the Deans and the

Faculty Board. Acceptance is contingent to availability of training

positions.

2.3 Provided that the above requirements are met, priority of admission to

internship training program will be as follows:

2.3.1 Imam AbdulRahman Bin Faisal University-College of

Public Health College graduates.

2.3.2 Graduates from other Saudi Universities.

2.3.2 Graduates from non-Saudi Universities.

2.4 All interns must pass the medical examination and have

required vaccinations as required by each academic

department.

3. Training Period

3.1 The duration of the program is one continuous Hijra Year and is

divided into four (4) rotations.

3.2 Interns training commences at the beginning of new academic year or

on date approved by the Dean of the College.


4. Training Sites

4.1 Internship training is conducted at King Fahd Hospital of the University

and/or other recognized government or private hospitals.

4.2 Training sites (hospitals) are determined by the HIMT departments

based on criteria ensuring higher standards.

5. Training Program Requirements

5.1. Internship Training is conducted through rotations/sections specific

for each specialty as determined by the HIMT departments.

5.2 Interns are required to work a minimum of 8 hours a day, 5 days a

week OR follow the affiliate hospital’s working hours.

5.3 A training manual is prepared by the HIMT department to include

requirements, rules and regulations, and evaluation forms specific to

each specialty. The training manual is updated on regular basis.

5.4. Interns are required to perform duties as assigned to them by

Supervisors and staff at the training sites.

5.5. Clinical rotations are scheduled in such a way that it meets Imam

AbdulRahman Bin Faisal University requirements for Internship

Training.

5.6. Interns must abide by the approved Internship Training Rules and

Regulations of Imam AbdulRahman Bin Faisal University –

College of Public Health, and rules and policies set by the affiliate

hospital(s).

5.7. Visits to training sites are scheduled to make sure that training is

conducted as planned.

6. Attendance/Leaves/Vacations

6.1 Interns are entitled to official vacation days (Eid-ul-Adha, Eid-ul-

Fitr, and the National Day).

6.2 Start and end of vacations are determined by the Dean of the College

in an official correspondence with affiliate hospitals and interns.


6.3 Sick and maternity leaves can be exceptionally granted, provided

that legitimate medical report is submitted.

6.4 Seven days are given for interns getting married. Any additional

days should be compensated.

6.5 Sick leaves of more than two days during one particular rotation must

be compensated.

6.6 All leaves of 25% or more of rotation period will result in repeating

the entire period of the rotation.

6.7 Interns must sign in and out attendance sheet, or time-keeping

schedule.

6.8 Frequent tardiness may result in the followings disciplinary

actions: 1) Written warning letter, 2) repeating part of the rotation,

3) repeating the entire rotation.

6.9 Interns may attend symposium/ workshops related to their HIMT,

and time is counted towards training period provided that:

a. Attendance does not affect continuity of training.

b. Approval from College of Public Health after reviewing

scientific program of the symposium.

c. Approval from training site (hospital).

d. Submission of attendance certificate.


7. Evaluation and Certification

7.1 Interns performance is assessed at the conclusion of each rotation

using standards Evaluation Form designed by respective academic

departments.

7.2 Evaluation of intern’s performance is done by clinical coordinator

or person who has been directly supervising the intern at the

training site.

7.3 Evaluation reports are to be submitted to the Dean of the College of

Public Health.

7.4 Unsatisfactory performance in particular rotation period requires

repeating that rotation.

7.5 Satisfactory performance is defined as grade GOOD or better.

7.6 Interns who have satisfactorily completed the Internship training

period (1 year) will be granted a Certificate of Completion.

8. Confidentiality Statement

All interns rotating to various affiliate hospitals will sign a

confidentiality statement form to protect the rights of the patient for

unlawful disclosure of any information from their medical record. See

Appendix 1 (Confidentiality Statement Form)


بكلية العلوم الطبية بكلية العلوم الطبية أنظمة ولوائح تدريب الامتيازأنظمة ولوائح تدريب الامتياز

التطبيقيةالتطبيقية

الإشراف الإداري على مرحلة الإمتياز: .أ

يشرف وكيل الكلية لشؤون التدريب على كل مايتعلق بتدريب الإمتياز من ناحية بداية .1

فيات في ذلك، التدريب وتوزيع الطلاب والطالبات على أماكن التدريب والتنسيق مع المستش

وكذلك متابعة أداء وتقييم الطلاب أثناء مرحلة الإمتياز.

يساعد وكيل الكلية لشئون التدريب ممثل عن كل قسم من الأقسام الأكاديمية يتم ترشيحه من .2

قبل رئيس القسم المعني.

قبول الطلاب في مرحلة الإمتياز: .ب

نهى بنجاح متطلبات التخرج من القسم يشترط للبدء في مرحلة الإمتياز أن يكون الطالب قد أ .1

الأكاديمي بكلية العلوم الطبية التطبيقية وان يصدر قرار من مجلس الكلية بالموافقة على

التخرج، ويمكن قبول خريجي الجامعات الأخرى بعد موافقة مجلس الكلية بشرط وجود

أماكن شاغرة للتدريب.

الي:الأولوية للقبول في برنامج الامتياز تكون كالت .2

أ. خريجو كلية العلوم الطبية التطبيقية بجامعة الملك فيصل.2

ب. خريجو كليات العلوم الطبية التطبيقية السعوديين من جامعة سعودية.2

ج. خريجو كليات العلوم الطبية التطبيقية من جامعات أجنبية.2

على جميع الطلاب المرشحون للامتياز استكمال التطعيمات .3

بة حسب متطلبات القسم.المطلو


ج. مدة مرحلة الامتياز:

( فترات.4مقسمة إلى ) تكون فترة التدريب لمرحلة الامتياز سنة هجرية. .1

تبدأ فترة التدريب الامتياز مع بداية العام الدراسي الجديد ، أو حسب التاريخ الذي يتم إقراره .2

من قبل وكيل الكلية لشؤون التدريب.

مرحلة الامتياز:برنامج التدريب ل .د

يقسم برنامج التدريب في مرحلة الامتياز الى دورات تدريبية يتم فيها توزيع التدريب على .1

الأقسام الرئيسية لكل تخصص على أن يتم تحديد هذه الدورات/ التخصصات من قبل الأقسام

الاكاديمية المعنية.

ي الأسبوع في التدريب العملي ساعات يومياً خمسة أيام ف 8يقضي طالب الامتياز على الأقل .2

أو يخضع لنظام ساعات العمل في القسم الذي يتم فيه التدريب .

كتيب التدريب العملي محتويا على أهداف التدريب ومتطلباته بإعداد الأكاديمية الأقساميقوم .3

يتم مراجعته وتحديثه بصوره دوريه. أنالى نماذج التقييم، على بالإضافة

وموظفي مسئولياز بتنفيذ المهمات المرتبطة بعمله والموكلة إليه من قبل يقوم طالب الامتي .4

القسم الذي يتم فيه التدريب.

يوضع برنامج مجدول للتدريب العملي من قبل القسم الذي يتم في التدريب وذلك بالتنسيق مع .5

امعة الملك الكلية على أن يتوافق ذلك مع متطلبات الامتياز بكلية العلوم الطبية التطبيقية بج

فيصل.

من قبل كلية العلوم الطبية المعتمدةيخضع طلاب مرحلة الامتياز لأنظمة ولوائح الامتياز .6

وكذلك أنظمة ولوائح المستشفى الذي يتم فيه الامام عبد الرحمان بن فيصلالتطبيقية بجامعة

التدريب.

ملية التدريب يوضع جدول لزيارة طلاب الامتياز في اماكن التدريب للتأكد من سير ع .7

التدريب. أثناءصعوبات قد تواجه الطلاب أيبالشكل الصحيح ولمناقشة

هـ. الحضور والإجازات:

يخضع طلاب الامتياز لنظام الإجازات الرسمية التالية )عيد الفطر، عيد الأضحى، اليوم .1

الوطني(.


لطلاب والمستشفيات يحدد بداية ونهاية الإجازة وكيل الكلية لشؤون التدريب ويتم إبلاغ ا .2

المعنية بذلك.

يمكن منح إجازة مرضية أو إجازة الولادة )بالنسبة للطالبات( بصورة استثنائية على أن يتم .3

إلى تقارير طبية موثقة في ذلك. الاستناد

.للمتدربين. أي أيام إضافية ينبغي تعويضبدل زواج يتم إعطاء سبعة أيام .4

عدى يومان على أن يتم ترتيب التدريب بالتنسيق مع يجب تعويض الإجازة المرضية التي تت .5

الكلية في ذلك.

من مدة الدورة التدريبية فيجب إعادة الدورة %25المرضية عن الإجازةإذا تعدت نسبة .6

التدريبية كاملة.

لطلاب الامتياز من قبل القسم الذي يتم فيه التدريب. والانصرافيجب توثيق الحضور .7

-ر أو الانصراف قد يؤدي إلى بعض أو كل العقوبات التالية:عدم الانتظام في الحضو .8

الدورة كاملة. انذارخطي، ب. إعادة جزء من الدورة التدريبية، ج. إعادة .أ

يمكن لطلاب الامتياز حضور المؤتمرات والندوات وورش العمل المتعلقة بتخصصهم .9

واحتساب تلك المدة من فترة التدريب وفقا للضوابط التالية:

لايؤثر حضور المؤتمر على التدريب العملي. أنأ. 8

ب. موافقة الكلية بعد مراجعة البرنامج العلمي للمؤتمر.8

ج. موافقة القسم الذي يتم فيه التدريب.8

صورة من شهادة حضور المؤتمر الى الكلية. إرسالد. 8

التقييم .و

ز في نهاية كل دورة أو قسم من التدريب باستخدام نماذج التقييم . يتم تقييم أداء طلاب الامتيا1

المعتمدة من قبل الأقسام المعنية.

. يتولى عملية التقييم مسئول/ منسق التدريب في المستشفى الذي يتم فيه التدريب.2

ترسل جميع تقارير التقييم إلى وكيل الكلية لشؤون التدريب لمراجعتها بالتنسيق مع القسم .3

عني.الم

اي من الدورات )أو الأقسام( التدريبية يؤدي إلى إعادة تلك الدورة )أو القسم ( اجتيازعدم .4

التدريبية.

.( على الأقلGood) الدورات التدريبية بنجاح يعني الحصول على تقدير جيد اجتياز .5

مرحلة الامتياز. إتمامبعد اجتياز كل الدورات التدريبية بنجاح يمنح الطالب شهادة .6


HIMT-Specific Internship Program Description

Introduction:

Following the completion of the study program, the student will spend one

year of training in recognized hospitals and health services facilities. The internship

training is divided into four rotations; each is 18 weeks long, excluding the two Eid

vacations.

The internship will be designed to provide the student with the opportunity

to integrate knowledge, behaviors, and professional attributes acquired throughout

the curriculum that are necessary to the practice of Health Information

Management and Technology. While at training organizations, the student will be

involved in developing insight, understanding and skill in the management of a

health information system. Moreover, students will be exposed to quality

management departments, facilities administration and management of information

departments. While the practical training in the fourth year was based mostly on

observation, the internship training is based on actual application.

At the end of each rotation, each intern should submit a report of the training

experience. The report should include the following:

The training plan

The duration of training in the different components

What was covered in the training

Courses that the intern attended

Special projects done

Good points in the training

Weak points in the training


Recommendations

Appendices

Professional Aims:

The aims of the Internship program are as follows:

1. Health Information Management: (for complete list of expected tasks see

Appendix 1)

A. Post-Discharge Processing:

1. Assemble hospital inpatient forms in the logical filing order according

to hospital policy.

2. Perform quantitative and qualitative analysis under supervision of

HIM specialist.

3. File and retrieve patient records according to the filing system used in the

hospital whether straight numeric filing or terminal digit filing.

4. Enter complete and accurate data into indexes and registers used by the

HIM Department.

5. To compile statistical report from patient health records for medical,

administrative, legal, and research purposes while ensuring the quality of the

organization’s data before compiling these reports.

B. ICD Coding

1. Extract Pertinent information from patient records and ICD-10 AM clinical

codes.

2. Query physician when code assignment are not straightforward or

documentation in the record is inadequate, ambiguous, or unclear for

coding purposes .

3. Brings identified coding concerns to supervisor’s attention for

resolution.

4. Use computerized encoders to assign ICD codes (if available).


C. Management of HIM Department:

1. Understand techniques used in the management of the health

Information department such as policy and procedure development

and the budgeting process.

2. Acquire and understanding of the release of information process by

handling patient information requests and inquiries.

3. Understand the medical record cycle in the visited health care facility

by observation and/or performing related duties.

4. Understand issues related to confidentiality , information security ,

information storage, and record retention as well authorship and authentication

of health record documentation, standardization , of medical vocabularies, and

use of classification systems .

2. Health Information Technology:

A. To understand the underlying technologies of the institution such as clients,

servers, network, databases, communication, and health systems.

B. To undertake train duties of various users in the institution on the use of

some of these technologies.

C. To work hands-on with these technologies in a productive manner according

to the needs of the institution.

D. To perform healthcare database administrator duties to whatever extent

possible in the institution.

3. Quality Control Management:

A. To come familiar with the different tools used for assessing quality of

healthcare rendered.

B. To become involved in the various stages of problem solving and evaluating

alternative solutions for problems that might occur during the internship.

C. To monitor various criteria, standards, and quality indicators present at the

institution.

D. To complete statistical report to support quality assurance activities.


4. Research

A. To help interns make the link between the theory of research and the practice

of research

B. To give interns any tools relevant for research (new software, courses etc)

C. To take interns through the different phases of research, from problem

identification, development of methodology, literature review, analysis ,

results discussion and conclusion

D. To train interns in the application/use of research findings in the hospital

setting

E. To train interns in the presentation of research findings in conference and in

academic publication

5. Health Economics and Business Administration (HEBA)

A. To train interns in the process of billing patients using information from the

information system

B. To training interns in the use of billing software

C. To train interns in the revenue cycle management

D. To train interns on the relationship between hospitals and payers

E. To train inters in other matters related to health economics and business

administration

6. Patient relations

A. To train interns in the understanding the procedures put in place to ensure

patient statisfaction

B. To train interns in the process handling patient complaints and resolving

them

C. To understand the legal implications of unresolved patient complaints


Internship Centers:

The main medical training centers include the following:

KFSHD King Fahd Specialist Hospital Dammam

KFHU King Fahd Hospital of the University

SAAD SAAD specialist Hospital

NGHA National Guard Health Affairs

SAMSO Saudi SAMSO Medical Services Organization

KFMMC King Fahd Military Medical Complex

DMC Dammam Medical complex

QATIF Qatif General Hospital

FMC_AK Family Medicine Center, Al Akrabiya

KFSHH King Fahd Specialist Hospital Hofuf

MCHD Maternal and Children Hospital, Dammam

JHENT Al Jabr ENT hospital, Al Hassa


CCoonnffiiddeennttiiaalliittyy SSttaatteemmeenntt FFoorrmm

Imam AbdulRahman Bin Faisal University College of Public Health

Department Of Health Information Management and Technology

CONFIDENTIALITY STATEMENT

........................................../ الطالبة: ... باسم الطال

................................الجامعي: .....................الرقم

.........: ...............................................التخصص

أتعهد أنا الطالب / الطالبة الموضح هويته أعلاه بأن احافظ علىى سىرية و وصوةىية

التىي أتلقىى التىدريب فيىه. مىا المعلومات المتعلقة بالمرضى المتواجىدي فىي المشتىى ى

أتعهد بالح اظ على سرية و وصوةية أية معلومة تتعلق بمكان التدريب.

الالتزام بأنظمىة و تعليمىات الامتيىاز ني مشؤول ع قراءة و فهم و ن ما أعلم تماما بأ

مىىا ورد فىىي تيىىب التىىدريب و مىىا يتعلىىق بهىىا مىى نمىىاةج و اجىىراءات اداريىىة. و أن أقىىوم

ء عملىىي بكىىا أمانىىة و اوىىلا حشىىب مىىا تتطلبىىه ابعىىراف المهنيىىة بمىىا يتوافىىق مىى بىىأدا

أنظمة و قواني المكان الذي اتلقى التدريب فيه.

_____________________ ___________________________

التـــــــــاريخ التوقيــــــــــــــ




INTERNSHIP TRAINING PROGRAM

APPLICATION FOR EMERGENCY LEAVE

Date Submitted:__________________

Name of Intern:___________________________________ ID#:________________

Specific Reasoning: ____________________________________________________

Date From: ______________________________ To: _________________________

Hospital Name: _______________________________________________________

Name & Signature of Person in Charge: ___________________________________

Please Fax this form to: 013 - 3330225

p

For University official Use ONLY

Intern to compensate leave: YES: ________ NO: ________

Revised Approved

_______________________________ _______________________________

Coordinator Vice Dean

HIMT Internship Training Training Affairs

Imam AbdulRahman Bin Faisl University


IMAM ABDULRAHMAN BIN FAISAL UNIVERSITY

COLLEGE OF PUBLIC HEALTH


HIMT INTERNSHIP ATTENDANCE FORM

Internship Center:

Intern University ID:

Intern Name:

Date Time In Intern Signature Time Out Intern Signature





Internship Evaluation Form

Student Name: Student ID:

Work Place: Training Period:

Supervisor: Hospital:

Assessment E VG G P Supervisor Comments

Attendance

Punctuality

Attitude in

working

environment

Initiation and

interest to learn

Technical Ability

Knowledge

Reliability and

work quality

Independence and

self confidence

Overall

Performance

E: Excellent VG: Very Good G: Good P: Poor

Additional Comments:

Number of Days Absent: Number of Days compensated:

Supervisor Name: Supervisor Signature:

Date: Official Seal:




Contacts of Training Affairs at College of Public Health

Vice Dean for Training Affairs

Dr. Abdulaziz AlMulla Phone 013/3331230

Director of Adminstration and

Finance

Mr Mohammed Radi al Faris

Phone: 013-3 31592

Mobile: 0505907273

HIMT Internship Coordinator

Dr Sulaiman Bah

Phone 013-3-31243

Mobile: 056-281-2189

Internship affairs email: [email protected]

Mailing address:

Dean of the College of Public Health

Imam AbdulRahman Bin Faisal

University

P.O. Box 1982

Dammam 31451

الصىحة العامةكلية عمىد

فيصل ن بنمام عبد الرحملاا جامعة

1982ص.ب:

31451الدمام




DEPARTMENT OF COMMUNITY HEALTH

HEALTH INFORMATION MANAGEMENT AND TECHNOLOGY PROGRAM

APPENDIX - I

List of Basic and Advanced Tasks for Each Rotation




DEPARTMENT OF COMMUNITY HEALTH

HEALTH INFORMATION MANAGEMENT AND TECHNOLOGY PROGRAM

Medical Record Department Rotation

SCOPE OF ACTIVITIES:

This rotation allows interns to practice in hospital medical record department and related

units to be able to perform basic medical records tasks such as patient admission and

discharge, filing of medical records, analysis and coding of medical records and release of

information. Interns are required to be involved in advanced health information

management tasks such as operational management of medical record department, data

quality review, research activities and information security.

LEARNING OBJECTIVES

By the end of the health information management rotation interns should be able to

perform:

I. Basic Tasks

A. Patient registration functions

1. Understand the medical record cycle

2. Admit and discharge a patient following correct procedures

3. Familiarize with patient registration at outpatient and emergency departments

B. Filing room procedures

1. Sort, file and retrieve medical records following correct procedures

2. Demonstrate the use of color coding of medical record folders

3. Apply procedures for tracking of medical records

4. Locate misfiled records

5. Implement hospital policies in relation to information storage and record

retention

C. Post-discharge processing activities

1. Assemble hospital inpatient forms in the logical filing order according to

hospital policy

2. Perform quantitative analysis according to hospital policy

3. Perform qualitative analysis according to hospital policy

4. Identify and report deficiencies

5. Enter complete and accurate data onto indexes and registers in use at the

medical record department


D. Coding and indexing

1. Abstracts pertinent information from patient records.

2. Assigns ICD-9-CM or ICD-10 codes according to hospital policy.

3. Queries physicians when code assignments are not straightforward or

documentation in the record is inadequate, ambiguous, or unclear for coding

purposes.

4. Brings identified coding concerns to supervisor or department manager for

resolution.

5. Use computerized encoders to assign ICD codes

E. Data analysis

1. Ensure the quality of the hospital's data before compiling reports.

2. Calculate basic hospital statistics including hospital census, hospital based-

morbidity and mortality statistics

3. Compile statistical reports from patient health records for medical,

administrative, legal, and research purposes.

4. Achieve competency in the use of computer applications for compiling the

above mentioned statistical reports

F. Release of information

1. Review facility’s confidentiality, information security and release of

information policies and procedures

2. Handles requests and inquiries for patient information

3. Maintain information flow according to the facility’s established guidelines

G. Other traditional health information functions

Interns should be exposed to other functions not covered in the above mentioned

core traditional medical record functions. These include but not limited to:

1. Orientation of transcription functions

2. Perform other related duties incidental to the work described herein.

II. Advanced health information tasks

The following tasks should be conducted under the direct supervision of the director of the

health information department:

A. Assist in the operational management of the medical record department through:

o Determination of the fiscal requirements and prepare budgetary

recommendations

o Monitor expenditure of budgeted funds.

o Establishment of schedules, task assignments and allocation of man hours to

assure compliance with departmental commitments

o Human resource management activities including, but not limited to, hiring,

performance appraisal, promotions and vacation schedules.

o Updating and modifying department’s policy and procedure

o Attend medical record department meetings

B. Review the quality of documentation of inpatient and outpatient records:

o Review of forms used in the hospital

o Identify areas for improving the content and format of forms

o Suggest new systems and methods to make data more accurate, complete and


accessible.

o Design and use audit tools to monitor the accuracy of clinical coding

Validate ICD-9 CM codes

Missed secondary diagnoses and or procedures

C. Develop statistical reports to help hospital administrators and clinical staff to:

o Monitor hospital spending

o Monitor hospital utilization

o Monitor physician practice patterns

D. Participate in clinical and administrative research activities:

o help in designing studies,

o Verify, examine and correct data

o Retrieve data from patient medical records or hospital databases

o Manipulate and analyze data by using statistical software

E. Assessment of information systems security

o Review the information security policies and procedures instituted by the

hospital

o Perform information security risk assessments

o Review/develop a preliminary disaster recovery and business continuity plans for

information systems

F. Conduct one seminar in each rotation

o to keep employees abreast of new concepts, techniques and changes in Health

Information Management as applied to the current situation


Information Technology Department Rotation

SCOPE OF ACTIVITIES:

This rotation allows interns to practice in the hospital’s information technology

department and related units to perform IT tasks such as:

1. Software client support and help desk

2. Software installation and configuration

3. Evaluation of different systems

4. Process modelling and evaluation

5. Surveys of user feedback of different systems

6. Form and report design and development

7. Creation of aggregate statistical queries

8. Database design and development of needed systems

9. Helping with the deployment of new systems

10. Training users on new systems


Quality Management in Healthcare Rotation

SCOPE OF ACTIVITIES

The rotation allows interns to practice the basic concepts of quality in health care

organizations as well as putting hands on the quantitative tools necessary for quality

management and improvement.

ROTATION OBJECTIVES

By the end of the rotation the intern is requested to,

I. Basic Tasks:

Document policies and procedures available at the department

Prepare at least ONE complete flowchart for a certain process

Prepare at least ONE clinical guideline procedure within a department selected

by the quality department supervisors

In case of available database, perform the monthly quality related rates at the

equivalent health care organization; e.g; number of admissions by sex, by age

group, number of patients by clinic (at the outpatient clinic), by department (for

inpatients), postoperative infection rate, etc; using various quality charts (e.g;

bar chart, histogram, pareto)

Preparation of control charts selected by the supervisors at the quality

department

II. Advanced Activities:

Attending quality team meetings and identification of priorities

Problem identification and root cause analyses for problems present within the

rotation time period

Participating in the steps of planning and monitoring of the opportunities for

quality improvement

Preparation, data collection, analysis and reporting of ONE patient satisfaction

questionnaire at the OPD and ONE for inpatients

Documents

College of Public Health Department of Health Information