Syllabus Information |
Spring 2025
Nov 23,2024 |
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 | Use this page to maintain syllabus information, learning objectives, required materials, and technical requirements for the course. |
| HIM 260 - Medical Record Auditing |
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Associated Term:
Spring 2025
Learning Objectives: Upon successful completion of this course, the student will be able to: 1. Explain the importance of accurate and complete medical record documentation for clinical care, compliance, and reimbursement 2. Identify the key elements of a medical record and describe how they support the delivery of high-quality patient care 3. Analyze medical records to identify errors, inconsistencies, and incomplete documentation that could result in clinical, legal, or financial risk 4. Apply documentation guidelines for ICD-10-CM and CPT coding to ensure accurate and consistent coding and billing 5. Develop a comprehensive audit plan that includes risk assessment, sampling, and data analysis methods for effective auditing 6. Evaluate clinical documentation to identify opportunities for improvement and develop strategies to address documentation deficiencies 7. Prepare and present audit reports that effectively communicate audit findings and recommendations to stakeholders, including clinicians, administrators, and compliance officers 8. Implement clinical documentation improvement initiatives that address deficiencies and enhance the accuracy and completeness of medical record documentation Required Materials: Technical Requirements: |
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