Course Description
Students are introduced to the theory and principles of health data classification utilizing CIHI Canadian Coding Standards, documentation standards. Students are also given knowledge of medical terminology, anatomy and pathophysiology. Students will learn to navigate ICD and CCI classification systems, electronic coding and abstracting systems and complete scenarios within the electronic health record to assign disease and intervention codes.
Course Content
In this course the learner will explore:
- The essentials of data classification including the coding process, principles, structure and guidelines pertaining to ICD and CCI
- The information and processes relevant to specified Major Clinical Categories including:
- Predisposing and risk factors
- Etiology
- Signs and symptoms
- Method of diagnosis
- Common complications and comorbidities
- Diagnostic and therapeutic interventions
- The application of the coding process and guidelines to assign appropriate diagnosis and intervention codes to the following:
- Infectious and parasitic diseases
- Neoplasms
- Endocrine, nutritional and metabolic diseases
- Diseases of the musculoskeletal system and connective tissue
- Diseases of the circulatory system
- Diseases of the respiratory system
- Diseases of skin and subcutaneous tissue
- Injury, poisoning and certain other consequences of external causes
- Symptoms, signs and abnormal clinical and laboratory findings
- Factors influencing health status and contact with health services
- Introductory pharmacology to augment the interpretation of case studies and the selection of appropriate disease and interventions code(s)
Learning Activities
Some or all of the following methods will be used:
- lecture/discussion
- case study analysis
- independent research
- group discussion and exercises
- presentation (individual or group)
- quizzes
- peer review
- instructor feedback
- individual consultation
Means of Assessment
The course evaluation is consistent with the Douglas College Evaluation Policy. An evaluation schedule is presented at the beginning of the course. This is a graded course. All assignments must be completed to pass the course.
Learning Outcomes
At the end of the course, successful learners will be able to:
- Apply knowledge of medical terminology, anatomy and pathophysiology to determine etiology
- Analyze case studies to determine principle diagnoses, interventions, complications and comorbidities
- Assess and apply international and national coding and documentation standards
- Navigate ICD, CCI, abstracting systems and electronic health records to complete the classification process
- Discover the importance of data integrity
Textbook Materials
A list of required and optional textbooks, materials and electronic applications is provided for students at the beginning of each semester.