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PLACE IN CURRICULUM:
INSTRUCTOR:
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 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
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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
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.
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(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:
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:
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.
STUDENT RESPONSIBILITIES
During 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
established
regulations 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 a
Clinical Notebook containing the Handbook, activity log, sample forms, and other pertinent
information 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 any
problems 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 RESPONSIBILITIES
The 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 department
3. providing instruction in specific health information management/medical record department
procedures or practices
4. evaluating the student's performance and achievement and reporting to the Professor directly
using evaluation methods agreed upon
5.contacting the Professor regarding scheduling conflicts or any problems with course
requirements and students.
PROFESSOR RESPONSIBILITIES
The 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.
1. Think of these clinical education sessions as "mini-jobs".
A. Act professionally, show initiative and interest.
B. Be prompt, punctual and prepared.
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The 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 students permanent folder in the Division Offices.
ATTENDANCE POLICY
Clinical 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 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 HIM
OBJECTIVES: 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/medical
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8. Identify the computer technology and software used for the chart management functions.
UNIT 4: MEDICOLEGAL AND RELEASE OF INFORMATION PROCEDURES
OBJECTIVES: 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 tecum
b. Release of patient information to insurance companies, former patients, physicians
(members and nonmembers of the medical staff), and health care facilities
3. 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
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
INFORMATION
OBJECTIVES: 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 reports
b. compilation of discharge analysis statistical information
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ASSIGNMENT TITLE
NUMBER
ASSIGNMENT TITLE
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LOCATION
ACTIVITY
TOTAL HOURS
SPENT
PASS/ SUPERVISOR
FAIL
SIGNATURE
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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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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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 FORMAT
Because 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 name
b. length of stay
c. patient's discharge disposition: alive, transferred to another facility, (specify),deceased.
d. definitions (see #4 & #5)
e. the items listed in #6
f. there should be one form of each record, use any word processing/spreadsheet/database
software
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 resources
b. most common signs and symptoms for the specified diagnoses as indicated by the above
listed resources
c. most common treatment modalities as indicated by the above listed resources
d. most common lab and diagnostic tests/procedures as indicated by the above listed
resources
e. List the most common types of medications given to the patient for this principal
diagnosis as indicated by the above listed resources
f. This information obtained from your medical record review can be handwritten on the
form/worksheet you designed
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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.
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_______________________
Student's Signature
_________________________
Clinical Supervisor's Signature
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