Fundamentals of Health Information Management

I.     Course Prefix/Number: HIT 121

       Course Name: Fundamentals of Health Information Management

       Credits: 3 (2 lecture; 2 lab)

II.    Prerequisite

Acceptance into Health Information Technology (HIT) program; HIT 104, BIO 231, with minimum grades of C. Recommended: Experience with Microsoft Office software.

III.   Course (Catalog) Description

Course examines health information management profession, healthcare delivery systems, health information functions, purpose, and users, health record content and documentation, data management, secondary data sources, overview of legal issues in health information management, data privacy and confidentiality and healthcare statistics.

IV.   Learning Objectives

  1. Describe the history and evolution of the health information profession, and the mission, membership, structure and operation, accreditation and certification programs, fellowship, foundation and ethics of the American Health Information Management Association (AHIMA).
  2. Discuss the standardization of medical care, the impact of regulations on healthcare delivery in the United States, and organization and operations of hospitals and other healthcare delivery settings.
  3. Describe the functions, purposes, formats, users, content and structure of a health record.
  4. Select a form(s) in the health record where a specific piece of data may be found and the corresponding healthcare professional who is responsible for the documentation.
  5. Differentiate between health information functions and processes in a hospital and other healthcare delivery settings (healthcare facilities) in a paper, hybrid, document management system or electronic environment.
  6. Differentiate between the documentation and completion requirements of accreditation organizations, state and federal regulations, and Medical Staff bylaws for all health record types.
  7. Analyze health records of discharged patients for deficiencies according to Joint Commission documentation standards.
  8. Utilize health information management software to perform health information functions and processes.
  9. Compare the different data elements in health records and documentation requirements for health records for the various health delivery settings and the different types of health information media and the healthcare delivery setting(s) in which they would be utilized.
  10. Explain data governance, data stewardship, data integrity, data sharing, data interchange standards, data quality, data collection tools and the characteristics of AHIMA’s Data Quality Management Model.
  11. Describe the types of secondary data sources of health records and uses of secondary data sources including facilities-specific indexes, registries and healthcare databases.
  12. Explain the legal issues related to ownership, control, and use and disclosure of health information, the importance of the definition of a legal health record in an electronic and hybrid health record environment, and how to apply legally sound health record retention and destruction principles.
  13. Apply use and disclosure policies and procedures that apply to both state law and Health Insurance Portability and Accountability Act (HIPAA) regulations in order to protect health information.
  14. Differentiate between the types, purposes, providers, users and healthcare related statistical terms (census, daily census, inpatient service days, etc.).
  15. Calculate healthcare statistics based on data provided.

V.    Academic Integrity and Student Conduct

Students and employees at Oakton Community College are required to demonstrate academic integrity and follow Oakton's Code of Academic Conduct. This code prohibits:

• cheating,
• plagiarism (turning in work not written by you, or lacking proper citation),
• falsification and fabrication (lying or distorting the truth),
• helping others to cheat,
• unauthorized changes on official documents,
• pretending to be someone else or having someone else pretend to be you,
• making or accepting bribes, special favors, or threats, and
• any other behavior that violates academic integrity.

There are serious consequences to violations of the academic integrity policy. Oakton's policies and procedures provide students a fair hearing if a complaint is made against you. If you are found to have violated the policy, the minimum penalty is failure on the assignment and, a disciplinary record will be established and kept on file in the office of the Vice President for Student Affairs for a period of 3 years.

Please review the Code of Academic Conduct and the Code of Student Conduct, both located online at

VI.   Sequence of Topics

  1. Health Information Management Profession
    1. History of Health Information Management
      1. Hospital standardization
      2. Organization of the Association of Record Librarians
      3. Approval of formal education and certification programs
    2. Evolution of practice
    3. American Health Information Management Association (AHIMA)
      1. Mission
      2. Membership
      3. Structure and operation
        1. Leadership
        2. Engage
        3. National committees
        4. House of Delegates
        5. State and local associations
        6. Staff structure
        7. Accreditation of educational programs
        8. Certification and registration program
        9. Fellowship program
        10. Foundation
    4. Health Information Management Specialty Professional Organizations
  2. Healthcare Delivery Systems
    1. Standardization of medical care
    2. Healthcare delivery in the United States
    3. Organization and operation of hospitals
      1. Types of hospitals
      2. Organization of hospital services
    4. Other types of healthcare services
      1. Ambulatory care
        1. Private medical practice
        2. Hospital-based ambulatory care services
        3. Community-based ambulatory care services
      2. Home Care
      3. Long-Term Care
  3. Health Information functions, purposes, and users
    1. Purposes of the health record
      1. Primary purposes
      2. Secondary purposes
    2. Formats of the health record
    3. Users of the health record
    4. Health Information Management (HIM) Functions
    5. Master Patient Index (MPI)
    6. Identification systems
      1. Identifications systems for paper-based health records
      2. Identification systems for electronic health records
      3. HIM functions in a paper-based environment
    7. HIM functions in an electronic environment
    8. Hybrid health records
    9. Medical transcription
    10. Release of information (ROI)
    11. Clinical coding
    12. HIM interdepartmental relationships
    13. HIM software
      1. Release of information
      2. Chart tracking
      3. Coding
  4. Health Record Content and Documentation
    1. Documentation standards
      1. Standards
      2. Medical staff bylaws
      3. Accreditation
      4. State statutes
      5. Legal health record
    2. General documentation guidelines
    3. Documentation by healthcare setting
      1. Inpatient medical and surgical health record
        1. Clinical data
        2. Administrative data
        3. Consents and authorizations
      2. Obstetric health record
      3. Newborn health record
      4. Emergency department health record
      5. Ambulatory health record
      6. Ambulatory surgery health record
      7. Physician office record
      8. Long-term care health record
      9. Rehabilitation health record
      10. Behavioral health record
    4. Health information media
      1. Paper health record documentation
      2. Electronic health record documentation
        1. Web-based document imaging
    5. Role of healthcare professionals in documentation
      1. Physicians
      2. Nurses
      3. Allied health professionals
    6. Health Information professionals and health record documentation
  5. Data Management
    1. Data Sources
    2. Data management
      1. Data elements, data sets, databases and indices
      2. Data mapping
      3. Data warehousing
    3. Data governance
      1. Data stewardship
      2. Data integrity
      3. Data sharing and data interchange standards
    4. Data quality
      1. AHIMA’s Data Quality Management Model
    5. Data collection tools
    6. Clinical Documentation Improvement (CDI)
      1. CDI tools
      2. Role of Clinical Documentation Specialist
    7. Data management and bylaws
      1. Provider contracts with facilities
      2. Medical staff bylaws
      3. Hospital bylaws
  6. Secondary data sources
    1. Differences between primary and secondary data sources
    2. Purposes and users of secondary data sources
    3. Types of secondary data sources
      1. Facility-specific indexes
        1. Disease and operation indexes
        2. Physician index
    4. Registries
      1. Cancer registries
      2. Trauma registries
      3. Birth defects registries
      4. Diabetes registries
      5. Implants registries
      6. Transplant registries
      7. Immunization registries
      8. Other registries
    5. Healthcare databases
      1. National and state administrative databases
        1. Medicare Provider Analysis and Review File (MEDPAR)
        2. National Practitioner Data Bank (NPDB)
        3. State administrative data banks
      2. National, state and county public health databases
  7. Legal issues in Health Information Management
    1. Overview of legal issues in Health Information Management
      1. Compilation and maintenance of health records
      2. Ownership and control of health records, including use and Disclosure
    2. Legal health record
      1. Importance of legal health record
      2. Content of legal health record
      3. Retention of the health record
        1. AHIMA retention recommendations
        2. Destruction
  8. Data privacy and confidentiality
    1. Use and disclosure
    2. State laws – privacy
    3. Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule and American Recovery and Reinvestment Act (ARRA)
      1. Overview
      2. Office of the National Coordinator for Health Information Technology (ONC)
      3. Applicability of the Privacy Rule
      4. Individual rights
      5. HIPAA Privacy Rule documents
      6. Uses and disclosures of health information
      7. Breach notification
      8. Requirements related to marketing, sale of information, and fundraising
      9. HIPAA Privacy Rule administrative requirements
      10. Enforcement of federal privacy legislation and rules
      11. Release of information
      12. Medical identity theft
      13. Patient verification
  9. Healthcare Statistics
    1. Introduction to health statistics
      1. Reasons for studying statistics
      2. Descriptive statistics versus inferential statistics
      3. Users of health statistics
    2. Mathematics review
      1. Fractions
      2. Rounding numbers
      3. Percentage
      4. Ratio
      5. Averages
    3. Patient Census
      1. Inpatient census
      2. Total inpatient service days
      3. Calculation of inpatient service days
      4. Average daily inpatient census
    4. Percentage of occupancy
      1. Percentage of occupancy
      2. Bed turnover rate
    5. Length of stay
      1. Length of stay
      2. Discharge days
      3. Average length of day
    6. Death (Mortality) rates
      1. Gross (hospital) death rate
      2. Net death rate
      3. Postoperative death rate
      4. Anesthesia death rate
      5. Maternal death rate
      6. Newborn death rate
      7. Fetal death rate
    7. Hospital autopsies and autopsy rates
      1. Gross autopsy rate
      2. Net autopsy rate
      3. Adjusted hospital autopsy rate
      4. Newborn autopsy rate
      5. Fetal autopsy rate
    8. Morbidity and other miscellaneous rates
      1. Infection rate
      2. Postoperative infection rate
      3. Complication rate
      4. Cesarean section rate
      5. Consultation rate
      6. Other rates

VII.  Methods of Instruction

Instruction includes lectures, projects, and group discussions based on reading assignments and worksheets; videos; laboratory practice using actual health records; field trip to a hospital Health Information department.

Course may be taught as face-to-face, hybrid or online course.

VIII. Course Practices Required

Course will be taught as a face-to-face course.

Students are required to attend classes, complete assignments, do required readings and participate in class discussions. Computers will be used to complete projects using hospital application software. The HIT lab and the AHIMA Virtual Lab will be used to simulate health information functions and processes.

IX.   Instructional Materials

Note: Current textbook information for each course and section is available on Oakton's Schedule of Classes.

Health Information Management Technology:  An Applied Approach, Nanette B. Sayles, AHIMA, Fifth Edition, 2016 required.

Documentation for Health Records, Cheryl G. Farenholz, Ruthan Russo, AHIMA, 2013 required.

Calculating and Reporting Healthcare Statistics, Loretta A. Horton, AHIMA, Fifth Edition, 2016 optional. 

Course website, computers, hardware, software, the Internet, AHIMA Virtual Lab and healthcare records.

X.    Methods of Evaluating Student Progress

Students will be evaluated on homework assignments, and exams. Grades will be determined on a cumulative point basis, which will be averaged. Grade distribution is as follows:

Grade distribution is as follows:
A = 94%
B = 88%
C = 82%
D = 76%
F = Below 76%

XI.   Other Course Information

CAHIIM Curriculum Entry-Level Competencies for Health Information Management (HIM) at the Associate Degree Level
Domain Entry-Level Competencies
I. Data Content, Structure & Standards Subdomain I.B. Health Record Content and Documentation
  1. Analyze the documentation in the health record to ensure it supports the diagnosis and reflects the patient’s progress, clinical findings, and discharge status
  2. Verify the documentation in the health record is timely, complete, and accurate
  3. Identify a complete health record according to organizational polices, external regulations, and standards
  4. Differentiate the roles and responsibilities of various providers and disciplines to support documentation requirements throughout the continuum of healthcare
Subdomain I.C. Data Governance
  1. Apply policies and procedures to ensure the accuracy and integrity of health data
Subdomain I.D. Data Management
  1. Collect and maintain health data
II. Information Protection: Access, Disclosure, Archival, Privacy & Security Subdomain II.B. Data Privacy, Confidentiality & Security
  1. Apply confidentiality, privacy and security measures and policies and procedures for internal and external use and exchange to protect electronic health information
  2. Apply retention and destruction policies for health information
III. Informatics, Analytics, and Data Use Subdomain III.A. Health Information Technologies
  1. Utilize software in the completion of HIM processes
Subdomain III.D. Healthcare Statistics
  1. Utilize basic descriptive, institutional, and healthcare statistics

If you have a documented learning, psychological, or physical disability you may be entitled to reasonable academic accommodations or services. To request accommodations or services, contact the Access and Disability Resource Center at the Des Plaines or Skokie campus. All students are expected to fulfill essential course requirements. The College will not waive any essential skill or requirement of a course or degree program.

Oakton Community College is committed to maintaining a campus environment emphasizing the dignity and worth of all members of the community, and complies with all federal and state Title IX requirements.

Resources and support for
  • pregnancy-related and parenting accommodations; and
  • victims of sexual misconduct
can be found at

Resources and support for LGBTQ+ students can be found at

Electronic video and/or audio recording is not permitted during class unless the student obtains written permission from the instructor. In cases where recordings are allowed, such content is restricted to personal use only. Any distribution of such recordings is strictly prohibited. Personal use is defined as use by an individual student for the purpose of studying or completing course assignments.

For students who have been approved for audio and/or video recording of lectures and other classroom activities as a reasonable accommodation by Oakton’s Access Disabilities Resource Center (ADRC), applicable federal law requires instructors to permit those recordings. Such recordings are also limited to personal use. Any distribution of such recordings is strictly prohibited.

Violation of this policy will result in disciplinary action through the Code of Student Conduct.