Document Sample

Course Outline
Course Number: HLTH

Course Description:

This course is the final course of the series where students will become proficient in
coding and abstracting health information utilizing ICD-10-CA and CCI using commonly
utilized abstracting software. Students will build on their skills and knowledge acquired
in the previous three semesters. Students will apply previous course knowledge to
inpatient, emergency and same day surgery source documents.


To enable the learner to become fully proficient in coding and abstracting a variety of
healthcare data while applying medical terminology, pathophysiology, data collection
guidelines and classification concepts.

Learning Outcomes:

Upon successful completion of this course the learner will be able to:

1. Demonstrate the value of data collection requirements in Canada in both the acute and
   ambulatory care setting.

      CHIMA objectives

1.1      Identify reasons for coding health data and the use of coding systems in data collection.
         [C-1-1 (2): Understand]
1.2      Demonstrate the importance of data quality on users and uses of data and information
         across the health care continuum [C-1-3 (1), Apply]
1.3      Understand the layout of data elements in the source document for coding purposes.
1.4      Data collection process based on user needs and how to get data when it does not exist.
         [C-1-1 (13), Understand]
1.5      Relate organized data elements (eg. Diagnosis to diagnosis type, gender to diagnosis, or
         postal code to address). [C-1-3 (8), Apply]
1.6      Explain how grouping and case weighting methodologies used in Canada and how
         diagnosis and intervention coded data are used within these systems (eg CMG, RIW,
         CACS). [C-1-1 (14), Understand]
1.7      Distinguish between terminology, nomenclature, classification, abstraction, encoding,
         and coding systems. [C-1-1 (4), Understand] ??? do in III or IV?
2. Apply ICD-10-CA and CCI coding conventions and Canadian Coding Standards to accurately
   code and abstract health information from paper and electronic source documents.

      CHIMA objectives

2.1      Apply knowledge of the general organization, key concepts, code structure and coding
         conventions utilized in ICD-10-CA and CCI [C-1-1 (5), Apply]
2.2      Apply Canadian coding standards for accurate code selection [C-1-1 (6); Apply]
2.3      Code and abstract diagnoses and interventions by specific body systems with accuracy
         and consistency utilizing the Folio software. [C-1-1- (5, 6, 7), Apply]
2.4      Apply knowledge of medical terminology to healthcare documentation while accurately
         coding patient records [A (1, 2, 4, 5, 6, 7. 9) Apply]
2.5      Demonstrate abstraction of health data using both paper and electronic source
         documents [C-1-1 (7), Apply]

3. Evaluate discrepancies in health record documentation utilizing knowledge of biomedical

      CHIMA objectives

3.1      Justify coding decisions by evaluating consistency and inconsistency between the health
         care professional’s diagnoses and the content of the complete health record (eg. is able
         to recognize whether an individual with pneumonia has been prescribed an antibiotic by
         referring to documentation such as orders and medication forms; if there is
         documentation of a transfusion and lower Hgb in lab but no diagnosis of anemia). [A
         (10); Evaluate]

4. Understand the importance of the application of privacy, security and confidentiality
   principles in health information practice to the coding and abstracting process [C-3-2 (1)
Learning Sequence: Winter: 2 lecture 2 lab
   Wks/Hrs           Topics, Resources, Learning      Learning   Assessment
     Units                    Activities              Outcomes
                Introduction to Course
               Review of ICODE Strategy
    Week 1
               Coding and Abstracting Review and        1-4
               Exercises Digestive System
               Primer Chapter 13
                Review ER Coding and FOBT
    Week 2     Review of Coding/Abstracting
               Inpatient/SDC Charts
               Coding and Abstracting Review and
               Exercises Nervous System and
    Week 3
               Vascular System (including strokes)      1-4
               Primer Chapter 22

                Coding and Abstracting Review and
    Week 4
                Exercises Pregnancy and Childbirth      1-4
                Primer Chapter 29
                Coding and Abstracting Review and
                Exercises Newborns and other
    Week 5      Neonates with Conditions
                Originating in the Perinatal Period
                Primer Chapter 30

                Other Reasons for Hospitalization
    Week 6      Primer Chapter 25
                Diagnosis Clusters

    Week 7      Feb 20 - No Class - Family Day

    Week 8
                Independent Learning Week
                Coding and Abstracting Review and
                Exercises Diseases and Disorders of
    Week 9      Male and Female Reproductive
                Primer Chapters 19, 20

                Coding and Abstracting Review
   Week 10      Kidney and Urinary Tract
                Primer: Chapter 18
                   Coding and Abstracting Review Post
    Week 11       Intervention Conditions
                  Primer Chapters 28

    Week 12
                  REVIEW and FINALS                             1-4

Course Description:

Students will build on the coding knowledge and skills learned in semesters two and
three. Coding will relate to the systems of the body currently being studied as well as to
the body systems studied in Coding and Classification Systems I and II. Students will
also continue to improve their skills in coding and abstracting.

Core Competencies and Essential Employability Skills

The student has reliably demonstrated the ability to:

   1. Analyze, evaluate, and apply relevant information to solve problems and make
      effective decisions
   2. Locate, select, organize, and document information using appropriate technology
      and information systems; use educational, presentation and information
      technologies to learn, collaborate, and communicate.
   3. Manage oneself and one's resources to achieve goals


   1. Accurately and consistently code and abstract a variety of health care data (ER,
      SDC, IP, CLI) using ICD-10-CA and an electronic abstracting system applying
      CIHI coding standards. (C1-LO2,C3-LO5,C3-LO7)
   2. Code charts from both formats (paper,scanned) demonstrating accuracy and
      consistency. (C3-LO5)
   3. Apply knowledge of medical terminology to healthcare documentation while
      accurately coding patient records. (B-LO3)
   4. Demonstrate respectful, appropriate professional behaviour and effective
       interpersonal interactions with others in the learning environment in accordance
       with the Fleming student rights and responsibilities document. (A-LO11)
   5. Demonstrate knowledge on the application of systems to track data collection
       requests while coding and abstracting. (E5-LO4)
   6. Evaluate requests for data capture within existing coding and abstracting
       framework to provide appropriate information to meet the needs of stakeholders.
       (C3-LO4, E5-LO1)
   7. Demonstrate an understanding of the relationship of grouping methodologies and
       how the methodologies affect funding. (C3-LO10,C3-LO11)
   8. Demonstrate an understanding of the evolutionary changes in data collection. (ie.
       CIHI coding and abstracting standards) (C3-LO9)
   9. Apply schemata to diagnoses and procedures that would facilitate sequencing,
       weighting, or ranking of conditions to allow for accurate clinical representation of
       severity, acuity, intensity and chronicity. (C3-LO8)
   10. Use the Folio Software to code diagnoses and procedures for specific body
       systems with accuracy and consistency considering the multi uses of the
       information. (C3-LO5,E4-LO8)
   11. Demonstrate knowledge of the commonly used classification and data abstraction
       systems. (ICD-10-CA, CCI, DSMIV). (C3-LO1,C3-LO7)

Additional Learning Outcomes Comments:
Classes will include presentations as well as lab time to gain experience coding
scanned/paper records using Folio and Cactus Abstracting

Learning Sequence Additional Comments:

This learning sequence may be subject to change in the case of unforeseen circumstances
at the College or to support guest speaker scheduling. The course professsor will
communicate these changes as quickly as possible.

Learning Resources:

Resources and manuals from CIHI
ICD-10-CA/CCI Classification Primer Fletcher, Joy - 5th Edition
2009 FOLIO Version(Provided by CIHI)
2009 CIHI Canadian Coding Standards

Assessment Plan:
 Item/Date:    Percent:                              Description:
  Test (Jan
                             Regular coding and abstracting tests worth 10% X 3 weeks
  26,Feb 9,      30
                             (Weeks 3, 5, 10)
   Mar 15)
Test (Feb 23)    20          Test on coding, abstracting, diagnosis typing covering
                    material from Week 1-6 (Week 7)
  Test (Mar         Test on coding, abstracting, diagnosis typing covering
     29)            material from Weeks 8-11(Week 12)
                    Completion of coding and abstracting on selected charts -
(Feb 16, Mar   20
                    (Week 6, 12)
                    Completion of 5 homework assignments - 2 marks each,
Assignment     10   random selection by faculty from all homework

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