OFFT 2050 - Introduction to Health Information

1. Data definitions, vocabularies, terminologies, and dictionaries
2. Data monitoring and compliance reporting
3. Data sources (primary/secondary)
4. Data storage and retrieval
5. Data versus information
6. Health record data collection tools (forms, screens, etc.)
7. Health record documentation requirements (such as accreditation, certification, licensure)
8. Healthcare data sets (such as OASIS, HEDIS, DEEDS, UHDDS)
9. National Healthcare Information Infrastructure (NHII)
10. Structure and use of health information (individual, comparative, aggregate)
11. Type and content of health record (paper, electronic computer-based, e-health-personal, web-based)

1. apply organization-wide health record documentation guidelines.
2. maintain the accuracy and completeness of the patient record as defined by organizational policy and external regulations and standards.
3. verify timeliness, completeness, accuracy, and appropriateness of data and data sources for patient care, management, billing reports, registries, and/or databases.
4. apply policies and procedures to ensure organizational compliance with regulations and standards.
5. manage health data (such as data elements, data sets, and databases).
6. apply clinical vocabularies and terminologies used in the organizations¿ health information systems.
7. analyze documentation in health records.
8. report compliance findings according to organizational policy.
9. assist in preparing the organization for accreditation, licensing, and/or certification surveys.
10. apply policies and procedures to ensure the accuracy of health data

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