Essential Functions

The purpose of the essential functions list is to allow prospective students who are considering a career to be informed of the physical, emotional, and psychological demands related to training and employment in a field of study. These lists are provided to allow prospective students to make informed career choices by providing them with a summary of the physical abilities and personality traits that are generally required for the successful completion of a curriculum and result in employment in a field of study after graduation. The tasks below are from the American Health Information Management Association's Registered Health Information Technician Domains, Sub-Domains, and Tasks and represent the program's essential functions:

Domain 1: Health Data Management

Sub-Domain A: Health Data Structure, Content, and Standards

Tasks

• Collect and maintain data sets and databases.
• Conduct qualitative analysis to ensure that documentation in the health record supports the diagnosis and reflects the progress, clinical findings, and discharge status.
• Comply with national patient safety goals as related to abbreviation usage.
• Apply clinical vocabularies and terminologies used in the organization's health information system.
• Verify timeliness, completeness, accuracy, and appropriateness of data and data sources (such as patient care, management, billing reports, and/or databases).

 

Sub-Domain B: Healthcare Information Requirements and Standards

Tasks

• Monitor the accuracy and completeness of the health record as defined by organizational policy, external regulations, and standards.
• Perform quantitative and qualitative analyzes of health records to evaluate compliance with regulations and standards.
• Apply policies and procedures to assure organizational compliance with regulations and standards.

 

Sub-Domain C: Clinical Classification

Tasks

• Use and monitor applications and work processes to support clinical classification and coding.
• Apply diagnosis/procedure codes using ICD-10-PCS.
• Apply procedure codes using CPT/HCPCS.
• Ensure accuracy of diagnostic/procedural groupings (such as APC, DRG, IPF).
• Adhere to current regulations and established guidelines in code assignment.
• Validate coding accuracy using clinical information found in the health record.
• Identify discrepancies between coded data and supporting documentation.

 

Sub-Domain D: Reimbursement Methodologies

Tasks

• Apply policies and procedures for the use of clinical data required in reimbursement and prospective payment systems (PPS) in healthcare delivery (such as APC, DRG, RVU, RBRVS).
• Support accurate revenue cycle through coding.
• Use established guidelines to comply with reimbursement and reporting requirements (such as National Correct Coding Initiative (NCCI), Local Medical Review Policies (LMPRP).

 

Domain 2: Health Statistics, Biomedical Research, and Quality Management

Sub-Domain A: Healthcare Statistics and Research

Tasks

• Extract and maintain data from clinical indices, databases, and registries.
• Collect, organize, and present data for administrative purposes, financial purposes, performance improvement programs, and quality management.

 

Sub-Domain B: Quality Assessment and Performance Improvement

Tasks

• Participate in facility-wide quality assessment program.
• Present data in verbal and written forms.

 

Domain 3: Health Services Organization and Delivery

Sub-Domain A: Healthcare Delivery Systems

Tasks

• Comply with accreditation, licensure, and certification standards from government (national, state, and local levels) and private organizations (such as the Joint Commission on the Accreditation of Healthcare Organizations).
• Apply policies and procedures to comply with the changing regulations among various payment systems for healthcare services such as the Centers for Medicare and Medicaid Services (CMS) and managed care.
• Differentiate the roles of various providers and disciplines throughout the continuum of healthcare and respond to their information needs.
• Understand the role of various providers and disciplines throughout the continuum of healthcare services.

 

Sub-Domain B: Healthcare Compliance, Confidentiality, Ethical, Legal, and Privacy Issues

Tasks

• Implement the legal and regulatory requirements related to health information.
• Apply regulatory policies and procedures for access and disclosure of protected health information (PHI).
• Maintain user access logs/systems to track access and disclosure of patient-identifiable data.
• Identify and report privacy issues/problems.
• Demonstrate and promote legal and ethical standards of practice.
• Report compliance issues according to organizational policy.
• Collaborate with staff to prepare the organization for accreditation, licensing, and/or certification surveys.
• Implement health record documentation guidelines and provide education to staff.

 

Domain 4: Information Technology and Systems

Sub-Domain A: Information and Communication Technologies

Tasks

• Use technology, including hardware and software, to ensure data collection, storage, analysis, retrieval, and reporting of information.
• Use common software in the completion of HIM processes (such as chart management, coding, release of information).
• Use specialized software applications (such as spreadsheets, databases, presentations, and e-mail) to execute work processes.
• 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 administration applications.
• Protect data integrity using software or hardware technology in which integrity means that data are complete, accurate, consistent, and up-to-date.

 

Sub-Domain B: Data Storage and Retrieval

Tasks

• Use appropriate electronic or imaging technology for data/record storage.
• Maintain the integrity of patient numbering and filing systems.
• Design forms, computer input screens, and other health record documentation tools.
• Maintain integrity of master patient/client index/enterprise master patient index.
• Query and generate reports using appropriate software.
• Design and generate reports using appropriate software.
• Coordinate, use, and maintain archival and retrieval systems for patient information (such as multiple formats).

 

Sub-Domain C: Data Security

Tasks

• Apply confidentiality and security measures to protected health information.
• Apply departmental and organization data and information system security policies.
• Use and summarize data compiled from audit trail.

 

Sub-Domain D: Healthcare Information Systems

Tasks

• Collect and report data on incomplete records and timeliness of record completion.
• Maintain filing and retrieval systems for health records.

 

Domain 5: Organizational Resources

Sub-Domain A: Human Resources

Tasks

• Apply the fundamentals of team leadership.
• Develop and/or contribute to strategic plans, goals and objectives for area of responsibilities, and job descriptions.
• Develop and conduct performance appraisals.
• Participate in intradepartmental and interdepartmental teams and committees.
• Develop and implement staff orientation and training programs.
• Provide consultations, education, and training to users of health information, including internal users such as healthcare providers and administrators.
• Assess, monitor, and report quality standards and productivity standards.
• Perform staffing analysis to determine adequate coverage.
• Prioritize job functions and activities.
• Use quality improvement tools and techniques to assess, report, and improve processes.
• Promote customer relations.
• Apply the principles of ergonomics in work process design.
• Comply with local, state, and federal regulations regarding labor relations.

 

Sub-Domain B: Financial and Physical Resources

Tasks

• Determine and monitor resources such as staff, equipment, and supplies in order to meet workload needs.
• Make recommendations for items to include in budgets.
• Monitor coding and revenue cycle processes.
• Recommend cost-saving and efficient means of achieving work processes and goals.