Domain I: Health Data Management

Subdomain A. Health Data Structure, Content and Standards

1. Collect and maintain data sets and databases

2. Conduct qualitative analysis to assure that documentation in the health record supports the diagnosis and reflects the progress, clinical findings and discharge status

3. Apply clinical vocabularies and terminologies used in the organization's health information systems

4. Comply with national patient safety goals as related to abbreviation usage

5. Verify timeliness, completeness, accuracy, and appropriateness of data and data sources (e.g., patient care; management; billing reports and/or databases)

Subdomain B. Healthcare Information Requirements and Standards

1. Monitor the accuracy and completeness of the health record as defined by organizational policy, external regulations and standards

2. Perform analysis of health records to evaluate compliance with regulations and standards:

 a. Quantitative analysis

 b. Qualitative analysis

3. Apply policies and procedures to assure organizational compliance with regulations and standards

Subdomain C. Clinical Classification Systems

1. Use and monitor applications and work processes to support clinical classification and coding

2. Apply diagnosis/procedure codes using ICD-9-CM

3. Apply procedure codes using CPT/HCPCS

4. Ensure accuracy of diagnostic/procedural groupings (e.g., APC; DRG; IPS)

5. Adhere to current regulations and established guidelines in code assignment

6. Validate coding accuracy using clinical information found in the health record

7. Identify discrepancies between coded data and supporting documentation

Subdomain D. Reimbursement Methodologies

1. Apply policies and procedures for the use of clinical data required in reimbursement and prospective payment systems (PPS) in healthcare delivery (e.g., APC; DRG; RVU; RBRVS)

2.  Support accurate revenue cycle through:

  a. Coding

3. Use established guidelines to comply with reimbursement and reporting requirements (e.g., National Correct Coding Initiative [NCCI]; Local Medical Review Policies [LMRP])

Domain 2: Health Statistics, Biomedical Research and Quality Management

Subdomain A. Healthcare Statistics and Research

1. Abstract and maintain data for clinical indices/databases/registries

2.  Collect, organize, and present data for:

a. Administrative purposes

b. Financial purposes

c. Performance improvement programs

d. Quality management

Subdomain B. Quality Assessment and Performance Improvement

1. Participate in facility-wide quality assessment program

2. Present data in verbal and written forms

Domain 3: Health Services Organization and Delivery

Subdomain A. Healthcare Delivery Systems

1. Comply with accreditation, licensure, and certification standards from government (national, state, and local levels) and private organizations (e.g., Joint Commission on the Accreditation of Healthcare Organizations [JCAHO])

2. Apply policies and procedures to comply with the changing regulations among various payment systems for healthcare services such as Centers for Medicare and Medicaid Services (CMS), managed care

3. Differentiate the roles of various providers and disciplines throughout the continuum of healthcare and respond to their information needs

4. Understand the role of various providers and disciplines throughout the continuum of healthcare services

Subdomain B. Healthcare Compliance, Confidentiality, Ethical, Legal, and Privacy Issues

1. Implement the legal and regulatory requirements related to health information

2. Apply regulatory policies and procedures for access and disclosure of protected health information (PHI)

3. Maintain user access logs/systems to track access to and disclosure of patient-identifiable data

4.Identify and report privacy issues/problems

5. Demonstrate and promote legal and ethical standards of practice

6. Report compliance issues according to organizational policy

7. Collaborate with staff to prepare the organization for accreditation, licensing and/or certification surveys

8. Implement health record documentation guidelines and provide education to staff

Domain 4: Information Technology and Systems

Subdomain A. Information and Communication Technologies

1. Use technology, including hardware and software, to ensure data collection, storage, analysis, retrieval and reporting of information

2. Use common software applications (e.g., spreadsheets; databases; presentation; email) in the execution of work processes

3. Use specialized software in the completion of HIM processes (e.g., chart management; coding; release of information)

4. Apply policies and procedures for the use of networks, including intranet and internet applications to facilitate the electronic health record (EHR), personal health record (PHR), public health, and other administrative applications

5. Protect data integrity using software or hardware technology (Note: Integrity means that data should be complete, accurate, consistent and up-to-date)

Subdomain B. Data, Storage and Retrieval

1. Use appropriate electronic or imaging technology for data/record storage

2. Maintain integrity of patient numbering and filing systems

3. Design forms, computer input screens, and other health record documentation tools

4. Maintain integrity of master patient/client index/Enterprise Master Patient Index (EMPI)

5. Query and generate reports using appropriate software.

6. Design and generate reports using appropriate software

7. Coordinate, use and maintain archival and retrieval systems for patient information (e.g., in multiple formats)

Subdomain C. Data Security

1. Apply confidentiality and security measures to protected health information (PHI)

2. Apply departmental and organizational data and information system security policies

3. Use and summarize data compiled from audit trail

Subdomain D. Healthcare Information Systems

1. Collect and report data on incomplete records and timeliness of record completion

2. Maintain filing and retrieval systems for health records.

Domain 5: Organizational Resources

Subdomain A. Human Resources

1. Apply the fundamentals of team leadership

2.  Develop and/or contribute to:

a. Strategic plans, goals and objectives for area of responsibility/responsibilities

b. Job descriptions

3. Develop and/or conduct Performance Appraisals

4. Participate in intra-departmental and inter-departmental teams/committees

5. Develop and implement staff orientation and training programs

6.  Provide consultation, education, and training to users of health information:

a. Internal users (e.g., healthcare providers; administrators)

7.  Assess, monitor, and report:

a. Quality standards

b. Productivity standards

8. Perform staffing analysis to determine adequate coverage

9. Prioritize job functions and activities

10. Use quality improvement tools and techniques to assess, report and improve processes

11. Promote positive customer relations

12. Apply the principles of ergonomics in work process design

13. Comply with local, state and federal regulations regarding labor relations

Subdomain B. Financial and Physical Resources

1. Determine and monitor resources to meet workload needs including staff, equipment and supplies

2. Make recommendations for items to include in

    budgets.

3. Monitor coding and revenue cycle processes

4. Recommend cost-saving and efficient means of achieving work processes and goals