Florida A&M UniversitySchool of Allied Health Sciences

Division of Health Information ManagementSummer 2015

COURSE NUMBER AND TITLE: HIM 3806 - Clinical Education I

COURSE DESCRIPTION: Orientation to health information functions within healthcare facilities. Rotation through technical

functions of the department following the flow of the patient’s record after discharge, including analysis, and correspondence, storage, retrieval, and control procedures.

PREREQUISITE: HIM 3006

CREDIT: 1 hour

TIME FOR PRESENTATION: 4-8 clinical hours per week, 64 total hours during semesterMondays and Wednesdays, 8:00am - 12:00p.m.

PLACE IN CURRICULUM: Summer Semester, Junior Year

INSTRUCTOR: Lon’Tejuana S. Cooper, PhD, RHIA, CPMOffice location: 331 Lewis/Beck Allied Health BuildingOffice number: 850-561-2025 lontejuana.cooper@famu.edu

Office Hours: Mondays 11:30a.m. – 12:30p.m. Wednesdays 2:00-3:00p.m

Please feel to email me to schedule an appointment time outside of the hours provided above.

METHOD OF PRESENTATION: After an initial orientation period in the HIM Lab on campus, the student will visit area hospitals and other healthcare facilities during which the student will rotate through various areas of the health information/medical record department or attend presentations given by the Professor (or Professor).

The student will complete projects and assignments concerning the relationship between the HIM department and various other facility departments. Other projects will show how the

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healthcare organization fits into the scheme of health services delivery and the impact of HIM in the organization. Assignments will focus on the theory and rationale of the work in the organization to which the student has been assigned.BLACKBOARD POLICY WITH INSTRUCTIONS:

This is a web assisted class. Students are responsible for enrolling in Blackboard and viewing it regularly for information. Blackboard uses the student’s FAMU e-mail. Therefore, it is the student’s responsibility to check and empty the e-mail box regularly.

Policy –1. Points will be deducted for students exceeding the allotted time assigned for tests.2. Time allotted for the test is determined by content and level of difficulty, not the

length of class.3. No restarts will be permitted for tests. You will be required to take a paper exam

consisting of different questions covering the same subject areas. Students will be required to provide their on print paper.

4. Students must be signed-in to the test within 15 minutes of the test start time. 5. If applicable, SafeAssign will be used for assignments submitted through

Blackboard. It is the student’s responsibility to become familiar with the SafeAssign submission process. Grades may be determined according to the extent of plagiarism.

**Students are to obtain a local telephone number; otherwise the FAMU email address will be the only means for the professor to contact the student.

METHOD OF EVALUATION:For each facility visited, the student is expected to:

1. Perform the specific task(s) assigned by the Clinical Supervisor for that clinical site and complete the information for the Clinical Report.

2. Complete typewritten reports that address the specific questions listed in the Clinical Report Requirements and the Daily Diary and Site Journal Format.

3. Complete the assigned Workbook exercises and submit these in the Clinical Notebook.

4. Maintain a Clinical Notebook that contains all of the clinical report, diaries, journals workbook exercises, lab projects, attendance sheet, and any special projects that may have been assigned. Examples/copies of facility procedures, forms, etc., should also be kept in the Clinical Notebook for future reference

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5. Maintain the attendance log/check-off sheet with Clinical Supervisor's signature and evaluation in the Clinical Notebook.

6. Maintain weekly peer review evaluation form in notebook.

7. Completion of background check, purchase of polo, and name tag

8. You must be present for Clincals for the entire duration to earn your total hours or you will have to make them up (total of 64 hours).

9. You must complete 2 additional independent hours per week. You must maintain a log sheet and you must obtain your Professors signature per week.

10. The above must be met or you may receive an unsatisfactory grade for this course.

The Clinical Notebook is to be submitted to Dr. Cooper by July 24, 2015.

GRADING SCALE: S = Satisfactory U = Unsatisfactory In order for the student to receive a grade of "S" for this course, the following criteria must be met:

1. Punctual attendance and completion of the 64 scheduled clinical hours at various facilities and the FAMU-HIM Lab.

2. Completed clinical reports, daily diaries, assignments, workbook exercises, attendance logs and evaluations submitted in the Clinical Education Notebook.

3. The Clinical Education Notebook submitted to the Professor on or before the date specified for that particular semester.

“I” GRADE POLICY:A student who is passing a course, but has not completed all of the required work by the end of the term may, with the permission of the instructor, be assigned a grade of “I.”

Grades of “I” are not assigned to any course that a student fails to attend or if a student withdraws from the University.

A student should not register for a course in which incomplete grades have been received. If he or she does, the original “I” will automatically be changed to a permanent grade of “F.”

Incomplete “I” grades will not count as hours attempted in computing cumulative grade point averages.

It is the responsibility of the student to make arrangements with the instructor for the removal of an incomplete grade.

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All incomplete grades must be removed by the last day of classes of the term in which the student is next enrolled, or the grade will be changed to “F.”

TEXTS & REFERENCES:

Abdelhak, Mervat, et al. Health Information: Management of a Strategic Resource, 4th edition, W.B.Saunders Co., 2007.

LaTour, Kathleen, & Eichenwald, Shirley. Health Information Management: Concepts, Principles, and Practice, American Health Information Management Association, 2013.

Tyson-Howard, Carla & Thomas, Shirlyn, JB Review:Comprehensive Review Guide for Health Information RHIA & RHIT Exam Prep, 2009.

OVERVIEW: Clinical Education I is an off-campus directed practice designed to provide the student with an orientation to hospitals, ambulatory care clinics, regulatory and/or accrediting agencies, nursing homes, and non-traditional health care facilities. In facilities that have health information management/medical record departments, the student will rotate through various areas within the department with emphasis on the basic and technical functions of the department following the flow of the patient's record after discharge, including analysis, abstracting, medicolegal and correspondence procedures, as well as the study of policies and procedures related to these technical functions. Interdepartmental relationships, storage, retrieval, and control procedures will also be experienced. Rotation through other facilities will include observation and discussion of organization=s mission and how it relates to health information management practices. Exercises completed in the HIM Laboratory will also be performed to address the above topics.

AHIMA=S DOMAINS, SUBDOMAINS, TASKS for RHIA=sI. Domain: Healthcare Data Management

A. Subdomain: Health Data Structure, Content, and Standards1. Manage health data (such as data elements, data sets, and databases).2. Ensure that documentation in the health record supports the diagnosis and

reflects the patient’s, progress, clinical findings, and discharge status.B. Subdomain: Healthcare Information Requirements and Standards

1. Develop organization-wide health record documentation guidelines.2. Maintain organizational compliance with regulations and standards.3. Ensure organizational survey readiness for accreditation, licensing and/or

certification processes.4. Design and implement clinical documentation initiatives.

II.B. Subdomain: Quality Management and Performance Improvement

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1. Provide support for facility-wide quality management and performance improvement programs.

2. Analyze clinical data to identify trends that demonstrate quality, safety, and effectiveness of healthcare.

III. Domain: Health Services Organization and DeliveryB. Subdomain: Healthcare, Privacy, Confidentiality, Legal, and Ethical

Issues1. Coordinate the implementation of legal and regulatory requirements

related to the health information infrastructure.2. Manage access and disclosure of personal health information.3. Develop and implement organization-wide confidentiality policies and

procedures.4. Develop and implement privacy training programs. 5. Resolve privacy issues/problems. 6. Define and maintain elements of the legal health record. 7. Establish and maintain e-Discovery guidelines.

IV.C. Subdomain: Data Security

1. Protect electronic health information through confidentiality and security measures.

Bloom’s Taxonomy:

1 = Knowledge: The remembering (or recalling) of appropriate, and previously learned information

2 = Comprehension: Grasping the meaning of information

3 = Application: Applying previously learned information to new situations to solve problems

4 = Analysis: Breaking down information and interring (or finding evidence) to support divergent conclusions

5 = Synthesis: Applying prior knowledge and skills to create a new or original whole

ACADEMIC LEARNING COMPACT: For the Division of HIM Academic LearningCompact, refer to http://www.famu.edu(also enclosed at the end of the syllabus)

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ACADEMIC HONOR POLICY:Refer to Student Handbook for the Division of Health Informatics and Information Management. The University’s Academic Honor Policy is located in the FANG Student Handbook, under the Student Code of Conduct- Regulation 2.012 section.

ADA COMPLIANCE:To comply with the provisions of the Americans with Disabilities Act (ADA), please advise instructor of accommodations required to insure participation in this course.  Documentation of disability is required and should be submitted to the Learning Development and Evaluation Center (LDEC).  For additional information please contact the LDEC at (850) 599-3180.

POLICY STATEMENT ON NON-DISCRIMINATION:It is the policy of Florida Agricultural and Mechanical University to assure that each member of the University community be permitted to work or attend classes in an environment free from any form of discrimination including race, religion, color, age, disability, sex, marital status, national origin, veteran status and sexual harassment as prohibited by state and federal statutes. This shall include applicants for admission to the University and employment.

COURSE POLICIES: (attendance, tardiness, make-up examination, etc.)

Attendance:Roll is taken at the beginning of class. One unexcused absences are allowed per University policy. Tardiness is counted and is defined as not being present at the time the class officially begins. After the one allowed unexcused absences and one unexcused tardiness, 5 points per absence and 3 points per tardiness are deducted from a starting grade of 100. If the student is tardy, it is his/her responsibility to inform the instructor at the end of class of their attendance. Otherwise, the student will be marked as “absent.” If a student is tardy on the day when a test is being administered, 5 points will be deducted from that test score. Students who are late on test days will not be granted additional time after the end of class to complete the test. Because this is a clinical course, more than one unexcused absence or more than one tardiness may result in the student earning a “unsatisfactory” grade for the course.

Clinical is to be treated as if it were an actual job.

COURSE OBJECTIVES: At the completion of this course the student should be able to:

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Gain actual experience with the health information management services and functions in the hospital, ambulatory care settings, and other healthcare facilities.

Make the transition from theory to practice as a health information professional in regards to the various healthcare facilities.

Make the transition from theory to practice in the completion of assigned HIM exercises completed in the HIM Laboratory under the close supervision of the Professor that were not able to be experienced at a specific clinical site.

Observe the total organization and management of the health information system and its relationship to the entire healthcare facility.

Identify the major accrediting and licensing agencies for each healthcare facility.

Describe the relationship between regulatory agencies and the health care delivery system.

Explain the importance of public health monitoring and its impact on the delivery of health care services within a specific community.

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FACILITIES & ACTIVITIESI. Activities within the HIM Department: Hospitals & some of the Ambulatory Care Facilities

1. Orientation and Tours 2. Assembly & Analysis of Medical Records3. Numbering, Filing, Preservation of Records4. Medicolegal and Correspondence Procedures5. Birth Registration and Fetal Death Reporting Procedure6. Statistical Compilation, Display, and Retrieval of Health Information

II. Ambulatory/Non-tradition Health Care Facilities1. Psychiatric Hospital2. Family Practice Clinic3. Health Maintenance Organization4. Skilled Nursing Facility5. Public Health Clinic6. Ambulatory Surgery Center7. Rehabilitation Hospital8. State Regulatory Agency9. State Department of Health10. Other Specialty Facilities/Clinics

III. PresentationsSome scheduled clinical education sites will not have traditional HIM/MR Departmental

structures. Informative professional presentations will be given by the individuals indicated on the Contact Sheet. Due to class/organizational size, individualized student activities will not be performed. Objectives will be given for each presentation scheduled.

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STUDENT RESPONSIBILITIESDuring clinical courses, the student is responsible for:1. following the administrative policies, standards, and practices of the health care facility.2. reporting to the health care facility on time (see Attendance Policy) and following all

establishedregulations during the regularly scheduled operating hours of the facility.3. conforming to the standards and practices established by the School while in training at the health care facility.4. providing the necessary and appropriate uniforms required.5. transportation to and from clinical sites. 6. completing projects assigned by the Professor and/or Supervisor and maintaining aClinical Notebook containing the Handbook, activity log, sample forms, and other pertinentinformation which is to be turned in to the Professor at the end of the semester.7. contacting the Professor if assistance is needed concerning schedule conflicts or anyproblems with clinical sites and/or personnel. 8. evaluation of clinical experiences by typed reports that will be contained in the Clinical

Notebook.9. completing the activity logs for each clinical education session attended.

CLINICAL SUPERVISOR RESPONSIBILITIESThe Clinical Supervisor is responsible for:1. orienting the health care facility and department employees to their role in the HIM program 2. orienting the student to the health care facility and department3. providing instruction in specific health information management/medical record department procedures or practices4. evaluating the student's performance and achievement and reporting to the Professor directly using evaluation methods agreed upon5.contacting the Professor regarding scheduling conflicts or any problems with course requirements and students.

PROFESSOR RESPONSIBILITIESThe Professor is responsible for:1. providing a schedule of activities which allows for flexibility for the facility, Clinical

Supervisor,and student.2. arranging special educational activities, when appropriate.3. planning for special projects and serving as an advisor for the project, when appropriate.4. scheduling time for conferences on projects or other assigned activities, when appropriate.5. scheduling time for review of clinical evaluations with students

SPECIAL INSTRUCTIONS TO STUDENTS : Your clinical education experiences will be very important to each of you in your training as a Health Information Manager. The following are guidelines to make your experiences more meaningful to you, to the Clinical Supervisor, the Professor, and the HIM Faculty.

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1. Think of these clinical education sessions as "mini-jobs".A. Act professionally, show initiative and interest.B. Be prompt, punctual and prepared.C. Cooperate and follow rules, regulations, and instructions as given.D. Do not hesitate to ask questions when you do not understand.

2. Approach each area as a challenge. Remember, you will have the background and the knowledge to perform the tasks assigned but you will have a difficult time performing it correctly without the aid, guidance, and instruction of the Clinical Supervisor.

3. Each department follows different procedures and methods to accomplish the same tasks. Simply because the way a job is performed is contrary to your classroom instruction or experience does not mean it is wrong. Perhaps your classroom instruction would not work in this particular instance. Or, on the other hand, perhaps from previous experiences you realize that other methods would better. Each department is individualized. Never expect one department to function exactly in the same manner as another. This clinical experience is used to show the diversity between different institutions.

4. Use your time to its best advantage. Remember that the more you become involved with learning the functions of the health information management/medical record department, the more that you will gain to aid you in your profession.

5. Be prepared! Have all necessary materials (notepaper, writing utensils, schedule, notebook, and handbook) with you at your assigned clinical. Complete reading assignments prior to your clinical, when assigned.

WORK STATEMENTStudents shall be treated as trainees who have no expectation of receiving compensation or future employment from the Affiliate Facility. Students will receive no monetary compensation from the Affiliate Facility during their clinical internships for administrative/patient services rendered. In addition, the Affiliate Facility will not provide the student with any employee benefits or insurance such as liability, accident, disability, health, or life.

SCHEDULINGClinical Education is directed practice in a health care facility without pay. It is scheduled during the regular working hours of the day, usually Mondays and Wednesdays from11:30-1:00. Due to the nature of hospitals and other healthcare facility activities, FLEXIBILITY in scheduling is a necessity. Schedules may change on short notice. It is the student's responsibility to contact the Professor immediately if there are any questions or concerns about the clinical education schedule. Updates of the schedule will be given as needed. There will be no excused absences because each absence must be made up in order to obtain the total number of clinical education hours. Because of the large number of students and small number of facilities, it is extremely difficult, if not impossible to reschedule activities. Clinical site assignments and experiences are planned by the Professor in collaboration with the Clinical

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Supervisors.

The Clinical Supervisor is the EXPERT on the subject being taught. You are at the clinical site so that you may learn the actual processes performed in the health information management/medical record department.EVALUATIONSThe student will be evaluated by the Professor and the Clinical Supervisor. Although the Clinical Supervisor is responsible for completing the evaluation form, it may be necessary at times to delegate the direct supervision of the student's work to other facility personnel, either within or outside the health information management department. The Clinical Supervisor works closely with these other individuals in reviewing and evaluating the performance of the students in these areas. The activity logs are to be complete, accurate, and up-to-date. The student is responsible for maintaining this record. The Clinical Supervisor must sign off on the log the day of your assigned activity. This form is turned in at the end of the semester in the Clinical Notebook. The Professor signs this form at the completion of the clinical education rotation. This form is kept in the student’s permanent folder in the Division Offices.

ATTENDANCE POLICYClinical education is directed practice in a health care facility without pay. It is scheduled during the regular working hours of the day. Clinical site assignments are planned by the Professor in collaboration with the Clinical Supervisors. Allow for flexibility - site schedules may change due to unusual circumstances beyond our control.

1. Students are to report to the facility 15 minutes prior to the scheduled time to allow for notifying the Clinical Supervisor of your arrival and set-up for work.

2. There are no excused absences. All absences and tardiness episodes must be made up.3. Notify the Clinical Supervisor and the Professor if you will be absent or late. Messages shall

be left at the HIM office (561-2025) in addition to speaking directly with the Clinical Supervisor.

4. The Clinical Supervisor and the Professor will make arrangements for make-up. It may not possible to make up the scheduled time at the same clinical site. Make-up sites, times, and projects will be at the discretion of the Clinical Supervisor.

5. If a change in schedule is needed (valid excuse necessary), you must notify the Professor at least 48 hours in advance to obtain approval. A request form for the change in schedule must be submitted at that time to allow for planning the make-up session. See #4.

6. If a clinical visit conflicts with a regularly scheduled class, discuss this with the instructor for his/her approval of your absence from this class. All lecture notes, assignments, tests, quizzes, etc., are the responsibility of the student. An Excused Absence form is required to be completed and given to the instructor. This form can be obtained from the Professor.

7. If any scheduled clinical visits are missed by the student without notification of the a.) Clinical Supervisor, b.) Professor, and c.)the SOAHS/HIM Division, disciplinary action will result. Disciplinary action may include, but is not limited to any/all of the following: a. make-up of the missed clinical, b. verbal reprimand, c. written memorandum to student file, d. dismissal from the clinical education course, and/or e. other action(s) deemed

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necessary by the HIM Faculty. Dismissal from the Clinical Education Course may result in the inability to attend future Clinical Education and HIM courses.

UNIT I: ORIENTATION & INTRODUCTION TO HIMOBJECTIVES: At the completion of this unit, the student should be able to have the opportunity, either through a clinical site or the HIM Lab, to:

1. Demonstrate an understanding of the relationship between the health information/medicalrecord department and other hospital departments.2. Describe the relationship of the healthcare organization to the delivery of health services.3. Discuss the following:

a. the goals of the organization and/or department.b. the role of the RHIA and RHIT in the facility and/or department.c. the role of accrediting, licensure/certification agencies.

4. Identify existing forms for the primary record.5. Demonstrate an understanding of the relationship of the Health Information Department's

withother facility departments.6. Demonstrate access the Master Patient Index for patient and medical record information.7. Tour the hospital/facility and attend any required orientation; visitation to the various departments.8. Tour the health information/medical record department, when applicable.9. Identify the flow of the medical record through the various functions of the HIM Department.

UNIT 2: ASSEMBLY & ANALYSIS OF THE MEDICAL RECORDOBJECTIVES: At the completion of this unit, the student should be able to have the opportunity, either through a clinical site or the HIM Lab, to:

1. Observe an employee following the existing procedures for record assembly, analysis, and computer abstracting.2. Following existing procedure for record assembly, analysis, deficiency completion, and computer abstracting, use records from the following services, Medical Service, Surgical, Obstetrics, Newborn Nursery, to perform qualitative and quantitative analysis to evaluate compliance with regulations and standards.3. Perform concurrent review on medical records, if applicable.4. Describe the control system to ensure that the medical record department receives all recordsafter discharge of the patient. 5. Identify computer technology and software used in the process of chart management.6. Perform data collection of incomplete medical records and timeliness of the record

completionprocess.7. Observe the process of physician notification and suspension due to incomplete medical

records.

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UNIT 3: NUMBERING, FILING, AND PRESERVATION OF RECORDSOBJECTIVES: At the completion of this unit, the student should be able to have the opportunity, either through a clinical site or the HIM Lab, to:

1. Explain the control mechanisms for accurate filing.2. Describe numbering system used in the facility.3. Explain the record retention policy of the department.4. Identify how complete records are filed and be checked for accuracy.5. Describe the type of filing equipment used.6. Explain the system used for the destruction of records and any information kept on records that

are destroyed legally by a record retention program. 7. Describe the microfilm or computerized document imaging system.8. Identify the computer technology and software used for the chart management functions.

UNIT 4: MEDICOLEGAL AND RELEASE OF INFORMATION PROCEDURESOBJECTIVES: At the completion of this unit, the student should be able to have the opportunity, either through a clinical site or the HIM Lab, to:

1. Describe the established procedures for release of health information and confidentiality at the facility and the impact of HIPAA.

2. Review the established policies and procedures for the following:a. Preparation of a record for court following a subpoena duces tecumb. Release of patient information to insurance companies, former patients, physicians

(members and nonmembers of the medical staff), and health care facilities3. Examine a subpoena duces tecum and prepare the medical record for court using the

established procedure, if possible.4. Examine requests for patient information from insurance companies, patients, physicians, and

health care facilities and prepare replies using the established procedure.5. Prepare a medical record for court following receipt of a subpoena duces tecum, if possible.6. Prepare responses to requests for patient information received from insurance companies,

former patients, physicians, attorneys, other health care facilities, etc.7. Discuss the experiences related to the conduct of the health information manager in court with

the appropriate health information/medical record department staff.8. Identify computer technology and software used in the ROI process, for both internal and

external requests.9. Identify the computer security mechanisms used in the department and facility-wide.

UNIT 5: BIRTH, FETAL DEATH, AND DEATH CERTIFICATE REPORTING PROCEDURES (when applicable)OBJECTIVE: At the completion of this unit, the student should be able to have the opportunity, either through a clinical site or the HIM Lab, to:

1. Evaluate the role of the health information management professional in the completion and

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verification of birth, fetal death, and death certificates.2. Describe the policies and procedures for insuring confidentiality of information when

preparing the certificates. 3. Discuss the transmission of information process to the State Office of Vital Statistics.

UNIT 6: STATISTICAL COMPILATION, DISPLAY, AND RETRIEVAL OF HEALTH INFORMATIONOBJECTIVES: At the completion of this unit, the student should be able to have the opportunity, either through a clinical site or the HIM Lab, to:

1. Evaluate the adequacy of the organizational statistical reporting system.2. Apply control procedures to assure accuracy, consistency, and completeness of statistical data.3. Assess the established policies and procedures for the following -

a. compilation of census reportsb. compilation of discharge analysis statistical informationc. compilation of physician activity - incomplete charts, admissions, surgeries, etc.

4. Discuss the importance of accuracy of a monthly statistical report.5. Observe the process for any ad-hoc facility-wide statistical reports or requests.

CLINICAL EDUCATION I: HIM ABDELHAK WORKBOOK EXERCISE ASSIGNMENTS The following workbook exercises are meant to facilitate the clinical education learning experience by providing a systematic and comprehensive approach to typical activities that occur in the HIM field. They are to be completed during the scheduled HIM Lab sessions throughout the semester. It is recommended that the student incorporate a specific section within the Clinical Education Notebook for these assignments. These items can be found on Blackboard.

NUMBER ASSIGNMENT TITLE NUMBER ASSIGNMENT TITLE

1-2 Accreditations by the Joint Commission1-9 Medicare1-10 Continuum of Care2-4 HIM Ethics3-1 Consolidated Health Informatics Initiative3-2 ONC Update3-3 AHRQ Projects Related to Regional Health Information Networks3-4 Private/Nonfederal Activities4-1 Internal Data Sources4-4 Collection of Health Care Data Across the Health Care Continuum4-7 Uniform Hospital Discharge Data Set 4-12 Evaluation of Content of an Inpatient Acute Care Hospital Record4-13 Continuing Record Review

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4-14 Delinquent Record Statistics5-1 Current Forces in Electronic Health Record Systems5-3 In-service, Program on Confidentiality of Electronic Health Records5-4 Planning for Electronic Health Records

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CLINICAL EDUCATION ACTIVITY LOGComplete the following information for each day you attend a clinical education session. You are responsible for maintaining an accurate and complete log. The designated Clinical Supervisor must countersign for each activity on that particular day.

STUDENT NAME:___________________________________

DATE & LOCATION ACTIVITY TOTAL HOURS PASS/ SUPERVISOR TIME SPENT FAIL SIGNATURE

_______________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Clinical Supervisors: Please also complete the “CLINICAL EDUCATION STUDENT EVALUATION FORM” and return it to L. K. Burke.

__________________________________ ________________________Professor's Signature Date

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CLINICAL SITE REPORT REQUIREMENTS AND GUIDELINESDuring the clinical education, every attempt should be made to investigate the health information activities. Try to experience all the activities outlined in the objectives. Some activities may not be possible due to the uniqueness of the facility. This report outline is to be completed in addition to the Daily Diary of HIM Activities.

I. CLINICAL SITE1. Report presented by (student's name) and date.2. Name and address of facility.3. Name and title of health information manager/technician or contact person.4. Type of facility and functions performed.5. Ownership and funding source(s) of facility.6. Describe patient population - how patients are referred, volume, general level of care, etc.7. Approximate number of employees - list by profession: doctors, nurses, secretaries, etc.

II. HEALTH INFORMATION SERVICES1. Explain how health records are initiated and processed.2. Content of health record - include sample forms, if possible.3. Describe the filing system used - alpha, numeric, what indices/registries are maintained, etc.4. Record retention, storage of old records (microfilm?) and destruction of records.5. What coding process is used and how does it affect reimbursement?6. What statistical information is routinely kept - note any special reports or requirements. 7. How are policy and procedure manuals maintained, updated, etc. 8. Describe present or planned computer/information systems services.9. Discuss legal issues including HIPAA and release of information and record retention.10. Explain the QI, risk management, and/or utilization management requirements/processes.11. Explain the accrediting/licensing agencies and results of last survey, if applicable.12. What are the primary problem areas for this facility.

III. PRESENTATIONSIf attending an HIM presentation, give a summary of the presentation including facility, name/title of presenter, type of work performed, HIM relationship with facility/job duties, and would your interest in this type of position. Include any handouts given at presentation.

III. SUMMARYA. Give your impressions and constructive criticisms of the facility and the health

information services in detail as if you were a HIM consultant. Site specific examples regarding efficiency, morale, etc. You may compare/contrast this site with other sites you have experienced.

B. Site at least three positive impressions of the HIM Department and why you as a manager would want to have these things in your department. Site three negative impressions

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and what you would do to change or improve the situation.

C. Discuss the qualities of the management staff. Do you agree or disagree with their style of management? Was it effective? How were their relationships with their subordinates? And superiors?

D. Discuss the HIM Department's relationship with other departments - medical staff, administration, nursing, business office, other ancillary departments, etc.

CLINICAL EDUCATION SITE JOURNAL FORMATBecause many clinical sites offer different routines for each student, a "Daily Diary" will be used to address HIM concepts and training. Use the following format to assist in your summation of clinical activities. This is to be included in your Clinical Education notebook at the end of the semester. Do this section for each day you are assigned to a facility for clinical education.

1. What were your duties/tasks for the day?

2. Were you prepared; i.e. - Were you adequately trained by the supervisor/employee and did you understand the concept behind the duty/task?

3. Did you understand how this particular task fit into the rest of the work of the department?

4. Did you feel that you became proficient at this task?

5. If you were an "employee" at this facility, what did you like about the task? Dislike about the task?

6. If you were a HI Manager at this facility, how would/could you address the negative aspects in question #5?

7. If you were a HI Manager at this facility, what type of individual would best be suited for this job?

8. Was there anything else that you would have liked to learn more about at this facility but did not get the opportunity? Why? (Examples: lack of time, insufficient staff for training, etc.)

9. What were your general observations about the department - Did everyone seem to get along and help each other? Was it a stressful day? Why? How did you feel you were treated? If you were offered a job there, would you like to work at this facility? Any other comments you have regarding HIM in particular or in general?

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Clinical Education MEDICAL SCIENCE / CLINICAL PERTINENCE PROJECT

The following project is designed to facilitate the student's understanding of medical science and pathophysiology and the relevant documentation in the medical record for adequate patient care, quality improvement, and accreditation purposes.

Use any of the medical dictionaries and references available in the HIM Lab and the internet, such as WebMD for this exercise.

GENERAL DIRECTIONS:

1. Choose 5 records, all with different principal diagnoses. Be careful not to choose records that other students are using. These will be assigned to you the first week of the semester.

2. Make a list of these charts. Give a copy to Dr. Cooper by 5/14/15 and keep the original for your Clinical Notebook.

3. Design a form/worksheet to address the following: (additional information can be included on your form)

a. the patient's medical record number and nameb. length of stayc. patient's discharge disposition: alive, transferred to another facility, (specify),deceased.d. definitions (see #4 & #5)e. the items listed in #6f. there should be one form of each record, use any word processing/spreadsheet/database

software

Part I – The Audit (What’s’ Documented in the Record) – Also known as Quantitative Analysis

4. Define/describe all of the diagnoses (principal and all other subsequent diagnoses) that are listed in the medical record. Determine and confirm the principal diagnosis. You will need to look at a variety of reports to accomplish this task. Also record the length of stay for each patient. This information comes directly from the record. All of what you may need may not be in the record. This would be considered a deficiency.

5A. Describe the pathophysiology of the principal diagnosis only for each patient. Include the following: You should use the chart to complete this task.

a. etiology of the disease as documented in the chartb. most frequently listed signs and symptoms the patient experienced as documented in the

chartc. most frequently listed treatment modalities as documented in the chartd. most frequently listed lab and diagnostic tests/procedures as documented in the chart

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e. List the types of medications given to the patient for the principal diagnosisf. This information obtained from your medical record review can be handwritten on the form/worksheet you designed

Part II – Research and Investigation (What Should Have Been Listed in the Record)

5B. Describe the pathophysiology of the principal diagnosis only for each patient. Include the following: You should use your Medical Science text books, WebMD, internet etc.

a. etiology of the disease as stated by the above listed resourcesb. most common signs and symptoms for the specified diagnoses as indicated by the above listed resourcesc. most common treatment modalities as indicated by the above listed resourcesd. most common lab and diagnostic tests/procedures as indicated by the above listed resourcese. List the most common types of medications given to the patient for this principal diagnosis as indicated by the above listed resourcesf. This information obtained from your medical record review can be handwritten on the form/worksheet you designed

Part III –Qualitative Analysis

SPECIFIC INSTRUCTIONS FOR THE REVIEW: - Use Your Check-List

6. Evaluate the documentation in each of the medical records, by comparing the information in 5A with 5B:

a. Does the record state the etiology of the principal diagnosis in this particular case? (See

H&P, nursing assessment, discharge summary, physician notes, etc). Is the etiology of the principal diagnosis found in 5A consistent with the etiology of researched in 5B?

b. Are the signs and symptoms described by the patient and physician as documented in the medical record consistent with 5B (See H&P, nursing assessment, etc). List all signsand symptoms on your check sheet that were not consistent and specify source.

c. Was the treatment given to the patient in 5A consistent with what was found in 5B? (See discharge summary, operative notes, physician and nursing progress notes, etc.) List all treatments performed on your check sheet that were not consistent and specify source.

d. Where the diagnostic tests, etc performed in 5A consistent with 5B? How often

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were they repeated (if applicable)? Do they support the principal diagnosis? (See lab, radiology, etc). List all the various tests/procedures (not referring to treatment procedures here) performed on your check sheet that were not consistent and specify source.

e. Where the medications given to the patient in 5A consistent with what they should have received in accordance with 5B? (See nursing notes, medication sheets, physician orders, etc) List all medications given to the patient on your check sheet that were not consistent and specify source.

7. All completed forms are to be included in the Clinical Notebook to be submitted on the date specified in the Clinical Handbook.

Part IV – The Report

8. Status Report: Write a memo to the Chief of the Medical Staff, Dr. Misha McGlory, regarding your findings from this review. Include at least the following information:

a. The error rate for each criteria.b. In your opinion, does the medical documentation of each record meet TJC

requirements? Why or why not - explain! c. What criteria has the highest error rate?

d. List at least 2 recommendations to Dr. Ross on how to solve the problem(s) as you stated in B & C.

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HEALTH INFORMATION MANAGEMENTClinical Education Student Evaluation Form

Student Name:_____________________________ Clinical Course/Date:_________________Complete and return to Professor. Please rate the student using the following scale:

3=Excellent 2=Satisfactory 1=Unsatisfactory

1. Working Relations/ Professional Behavior: How well does the student work with the HIM staff; demonstrate professional judgment (consider appearance, behavior, attitude, and conduct)

3 2 1Remarks:

2. Attendance and Punctuality: How responsible is student to report at assigned times and dates?3 2 1

Remarks:

3. Quality of Work: How well does student perform HIM functions and specific instructions?3 2 1

Remarks:

4. Knowledge of HIM: How well does student understand/apply basic HIM concepts and/or specific knowledge of the assigned task?

3 2 1Remarks:

5. Organizational Skills: Is student prepared for given assignment, efficient, uses time wisely?3 2 1

Remarks:

6. Overall Rating of HIM student during this clinical education rotation:3 2 1

Remarks:

_______________________ _________________________Student's Signature Clinical Supervisor's Signature

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Clinical Education Site Information - Will be provided in a separate document.

Clinical Education Dress CodeTo prepare the students for the working environment of hospitals, health care facilities & other professional organizations, the following dress code has been developed. Appearance & image have a great impact on the perception of your professionalism. This is a good time to start collecting a business wardrobe for the Management Affiliation and future professional interviews.

FAMU-HIM nametag - must be worn at all times at clinical sites!

Dress business suits (or dresses) in dark colors: black, navy, gray, brown.*if wearing the lab coat, you do not have to wear the suit jacket at the clinical site.

Blouses(women)/dress business shirts(men): white or pastels, can be short-sleeved, no polo shirts or tank tops.

Pants (men or women): dress material (matches jacket), not denim or khaki or material that has double-stitched seams. Dress shorts NOT permitted at clinical sites.

Skirts/Dresses: dressy material, not denim, no shorter than 2 inches above the knee.

Clothes to Avoid: anything sheer or see-through, low-cut blouses/tops, tight-fitting garments, very short skirts/dresses (more than 2 inches above knee).

Ties (men): any color with a business/professional print or stripe (no cartoons).

Pantyhose for women and socks for men must be worn.

Low to mid heel pumps (women) and dress shoes(men) in dark colors to match outfit, no sneakers/tennis shoes, deck/casual shoes, sandals or open-toed shoes, very high heels(3"+).

Jewelry: small earrings (one pair) one necklace and/or bracelet, and a watch.

Hair: conservative, professional style, braids acceptable if neat and tied back if long length, one color only.

Personal hygiene: neat and clean, pressed and polished; toothpaste, soap & deodorant must be used prior to arrival at site; light application of perfume/aftershave; appropriate undergarments per gender; fingernails: no longer than one-half inch past tip of finger, one color polish only, no appliqués, pastel/red colors best, french polish acceptable

**Let the Clinical Supervisor remember you for the work you did,not for your clothes, fingernails or hairstyles!!**

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