Health Care Information Services
Grade 12

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Medical Records Management Standard 1: Students will understand medical records management systems. Students will know the purpose of formatting, types, content, and legal aspects of medical records. They will prepare, complete, audit, analyze, abstract, process, store, and retrieve medical records according to legal guidelines and facility policies.
Examples of the types of work students should be able to do to meet the standard:
  • Students prepare a sample patient record from a prepared patient case study.
  • Students research and report on three ramifications of improperly prepared medical records.
  • Students describe why medical records are considered legal documents.

Admitting Procedures Standard 2: Students will know in-patient and out-patient admitting procedures as related to patient diagnosis and understand how these procedures affect all other hospital services. They will collect demographic and insurance information and will perform patient admission procedures according to hospital policy.
Examples of the types of work students should be able to do to meet the standard:

  • Students prepare two sample admission forms, one in-patient and one out-patient, in a role play activity using patient interview techniques and a prepared case study.
  • Students determine the appropriate patient assignment based on the admission form information.
  • Students describe criteria for determining in-patient and out-patient status from prepared case studies.

Health Care Financial Management Standard 3: Students will understand the economic impact of billing, coding, and health insurance claims on health care providers. Students will know a variety of billing systems, collection procedures, types of insurance, and principles of complex diagnostic and procedural coding. They will collect patient data, verify coverage, process insurance claims, and use coding systems to maximize reimbursement within legal parameters.
Examples of the types of work students should be able to do to meet the standard:

  • Students collect and complete three sample third-party payer forms from prepared case studies.
  • Students describe how proper and improper coding affects reimbursement to be received and will give examples of each.
  • Students prepare a sample collection letter and in role play practice making collection phone calls.

Transcription Procedures Standard 4: Students will know medical transcription procedures and how to use equipment necessary to record complete documentation of patient care. They will operate the transcription equipment, transcribe, edit, proofread, and format appropriate medical documents according to policy.
Examples of the types of work students should be able to do to meet the standard:

  • Students transcribe three sets of doctor’s orders with different ethnic accents from transcription equipment.
  • Students edit each of three prepared reports for grammar, spelling, and content accuracy.

Health Unit Management Standard 5: Students will understand the function of diagnostic, therapeutic, and other health care services and how they relate to patient care. They will participate as members of the health care team to efficiently coordinate activities on a health care unit/department that impact delivery of patient care.
Examples of the types of work students should be able to do to meet the standard:

  • Students prioritize care assignments for a ten-bed surgical unit from case studies for each patient.
  • Students prepare a diagram illustrating lines of authority for incident reporting.
  • Students prepare a typical patient unit poster illustration and describe to classmates the functions of each item.
Samples of specific activities or tasks that give students the opportunity to demonstrate that they can meet the standard:
  • Given a set of confidential patient files, the student reviews each chart and distributes it to the appropriate department. Files that have been completed are filed in the appropriate area utilizing the coding and filing system of that department. Students prepare a written report of department protocols for patient file disbursement. They include in the report how each file is prioritized, transported, transferred or loaned to various departments/clinics.