Portland Community College | Portland, Oregon

Upon successful completion of the course, students should be able to:

1. Utilize software in the completion of health record analysis tasks.
2. Identify the documentation in the health record to ensure it supports the diagnosis and reflects the patient's progress.
3. Validate the acute care documentation in the health record is timely, complete, and accurate.
4. Define health data elements and data set terminology.
5. Collect and abstract data within the inpatient health record as part of the Uniform Hospital Discharge Data Set (UHDDS)

Students will demonstrate these learning outcomes by these tasks conducted individually and in cooperation with other students by:

1.  Successful completion of assigned modules as outlined on lab schedule.

1. Explain current formats for data and information collection and the various ways in which data and information are collected.
2. Understand data access and retention of paper-based, image-based and electronic information.
3. Transmitted information electronically via phone, fax and e-mail.
4. Maintain filing and retrieval systems for paper-based patient records.
5. Audit the master patient index for errors.
6. Identify the various professionals working in health care facilities.