February 16, 2016
Appendix 3B: Maintaining a Legally Sound Health Record, p. 115-147
Maintaining a legally sound health record includes the content, how they are recorded,
and the security of the record.
If EHRs are not maintained to
6) 52310 or 52352 Wasnt sure on this one, had a hard time figuring it out.
4) 58670 Had a hard time figuring this one out, had to
Embrace your future. HIM professionals must
continue to redefine and rebrand themselves
to thrive and embrace future opportunities.
1. Build a framework
to transform HIM
2. Position professionals
for the future
Why HIM Reimagined?
1. Which of the following is an example of an electronic data source in healthcare?
a. Radiology Information System
b. Patient consent for treatment
c. Dictation system
d. Patients drivers license
2. Which of the following datasets was created to collect
HIM 295: Seminar & Professional Practice Experience
Description: Practical experience in identifying diagnoses and procedures and
using appropriate coding systems and guidelines to assign codes.
Coding through use of app
Procedure: Stapedectomy (removal of entire stapes), right ear
Medical and Surgical
Ear, Nose, Sinus
Elements of a history
(equal to lowest category documented)
Chief Complaint _
HPI History of Present Illness
_ Location _ Duration _ Severity
_ Quality _ Context _ Timing
_ Modifying Factors _ Associated
Signs & Symptoms
ROS Review of Sy
Preparing for the marathon
How do you plan to study for
the RHIT exam
How to get started.
Preparing for a major exam is similar to
preparing for a marathon athletic event.
Study a little every day.
World Health Organization
ICD-10-PCS Medical and Surgical Root Operation Terminology*
Definition: Modifying the anatomic structure of a body part without affecting the
function of the body part
Explanation: Principal p
ICD-10-PCS Slide 1
Used only in the U.S.
Funded by CMS and developed by 3-M
Each code is designed to have a standard structure
Flexible enough to accommodate future procedural
ICD-10-PCS Slide 2
ICD-10-PCS 2014 has approximately
WESTERN KENTUCKY UNIVERSITY
HIM 100 Field Trip Experience Lab
HIM Field Trip Experience
At the conclusion of this laboratory assignment, the student
Will be able to:
1) Interview Directors of the depart
Practice Exercise for Neoplasms:
Classical Hodgkin disease of intrathoracic lymph nodes.
Benign neoplasm of left main bronchus.
Patient is admitted for chemotherapy for a distal esophageal carcinoma.
Carcinoma of the broad ligam
February 16, 2016
Ch. 3: Principal and Ancillary Functions of the Health Record, p. 92-114
This is a continuation of chapter 3. This portion is about the Health Record functioning as
a legal document.
The health record is usually cons
February 26, 2016
Chapter 4: Documentation for Statistical Reporting and Public Health, p.150-182
This chapter is about the data collected from health records for research and registries.
Indexes are used to sort data and to analyze c
Chapter 2A: Appendix 2A, p. 47-70
The purpose of this section is to more clearly define the differences between a legal
health record, designated health record set, source data, administrative and derived data.
Chapter 2: Clinical Documentation and the Health Record, p. 25-45
HIM professionals control the availability, completeness, and accuracy of health records.
They protect the rights of consumers by following the rules and standar
Chapter 1: Healthcare Delivery, p. 3-22
The main purpose of this chapter is to inform about the expansion of health care and the
growing need for transitioning to computer based programs. It also touches on the issues of
HIM 100 Lab
February 9, 2016
Ch. 3: Principal and Ancillary Functions of the Health Record, p, 72-92
There are four functions of the Health Record: patient-care delivery, patient-care
management, patient-care support, and billing and reimburs
Homework assignment #1
Please type in the correct answers.
1. How many sections are in the CPT codebook? Six
2. Name each of the sections. Evaluation and Management, Anesthesiology,
Surgery, Radiology, Path
PURPOSE of UM
Provide the highest quality services at the
lowest possible cost (provider)
Receive the highest quality services (patient)
Pay for the highest quality services at the
lowest possible price (payer)
History of Utiliza
Excisional Debridement: is the sharp removal of tissue at the wound margin or at the
wound base until viable tissue is removed. Coders report excisional debridement codes
(CPT codes 11042-11047) based on the deepest layer of viable tissue r
HIM 250C: Clinical Classification Systems
Medical Record Coding and Analysis Lab
At the conclusion of this laboratory assignment, the student should be
Questions From Test One
The patient was diagnosed with an advanced malignant carcinoid tumor of the ascending colon
with carcinoid syndrome. Medications are being prescribed to relieve the carcinoid syndrome
Case Study 1
MHA 642: Health Informatics
Health information exchange (HIE) allows physicians and other health care
providers to access a patients health records electronically. This feature offers
improvement in the speed and quality of care. HIE helps av