Lec1 HDCC PDF

Classi&ca(on Systems In Healthcare - 1  Course Descrip(on  This course will help the students to: o Understand the collection, coding and classi6cation of health data under the ICD-10 AM coding system. o Improve and increase eDciency in the...

Classi&ca(on Systems In Healthcare - 1  Course Descrip(on  This course will help the students to: o Understand the collection, coding and classi6cation of health data under the ICD-10 AM coding system. o Improve and increase eDciency in the " health 3ï I care system. o Capture the health information in a standard format, to support management, planning and delivery of health services, research and education. o understand data quality in health care and the ICD-10-AM classi6cation system, the current standard within Saudi  Course Learning Outcome Knowledge and understanding 1.1 Develop strategies for accurate and e3cient Clinical Coding Iden6fy the structure and organiza6on of the three volumes of WHO 1.2 ICD-10 and the Ave volumes of ICD-10 AM, ACHI and ACS Understand the conven6ons and instruc6ons used in WHO ICD-10, 1.3 ICD-10 AM, ACHI and ACS Iden6fy the principal diagnosis and principal procedure for 1.4 admission Select the appropriate condi6ons and procedures for coding from 1.5 medical records generated by an episode of care. 1.6 Assess the quality of coded data  Course Learning Outcome Skills Summarize the principles of coding healthcare data using the three 2.1 volumes of WHO ICD-10, and the Ave volumes of ICD-10 AM, ACHI and ACS Create principal diagnosis and procedure codes for appropriate pa6ent care 2.2 seKng Apply the Instruc6ons in the instruc6onal manual of WHO, ICD 10 and the 2.3 Australian Coding Standards in clinical coding. 2.4 DiLeren6ate conMic6ng clinical informa6on in the medical records.  Course Learning Outcome Values Construct adequate ICD-10-AM codes in a pa6ent encounter for diagnosis and 3.1 procedures independently. Perform update process for ICD-10-AM and other professional prac6ces in 3.2 managing health informa6cs. 3.3 ConAdent to communicate and work as a clinical coder Marks Distribu(on Examina(on Schedule Assignments 10 Marks Presenta6on 10 Marks Quiz 10 Marks Quiz aVer comple6on of Unit: TBD Midterm 20 Marks Final 50 Marks Midterm aVer comple6on of Unit:TBD Minimum 60/100 Final aVer comple6on of all units  Module (1-2)  Understanding the medical terminology language  Brief understanding of anatomy and physiology including the diRerent body systems Anatomy, Physiology and Medical Language OpenStax Anatomy and Physiology  Introduc(on to Medical Terminology Medical terminology is a language that is used in health care seKngs. Medical terms are built from Greek and La6n word parts and in addi6on include acronymns, eponyms, and modern-day language terms. Medical terms are built from word parts. Those word parts are pre&x, word root, suSx, and combining form vowel. When a word root is combined with a combining form vowel the word part is referred to as a combining form.  Pre$x Pre$xes are located at the beginning of a medical term. The pre6x alters the meaning of the medical term. It is important to spell and pronounce pre6xes correctly.  SuSx Su*xes are word parts that are located at the end of words. SuDxes can alter the meaning of medical terms. It is important to spell and pronounce suDxes correctly.  word parts Many medical terms are built from word parts and can be translated literally. building your medical terminology founda6on stay literal when applicable. It should be noted that as with all language rules there are always excep6ons, and we refer to those as rebels  word parts (Osteoarthri(s)  Oste/o/arthr/i(s – InWamma(on of bone and joint. Oste/o is a combining form that means bone arthr/o is a combining form that means joint -i6s is a suSx that means inMamma6on No(ce, when breaking down words that you place slashes between word parts and a slash on each side of a combining form vowel.  word parts (Intravenous) Intra/ven/ous – Pertaining to within a vein. Intra- is a pre&x that means within ven/o – is a combining form that means vein ous is a suSx that means pertaining to  Language Rules for Building Medical Terms  Gastr/o/enter/o/logy – The study of the stomach and the intes6nes Following rule 1, when we join combining form gastr/o (meaning stomach) with the combining form enter/o (meaning intes6nes) we keep the combining form vowel o. Following rule 2, when we join the combining form enter/o (meaning intes6nes) with the su3x -logy (that starts with a su3x and means the study of) we keep the combining form vowel o  Language Rules for Building Medical Terms  Intra/ven/ous – Pertaining to within the vein Following rule 3, no6ce that when combining the combining form ven/o (meaning vein) with the su3x -ous ( that starts with a vowel and means pertaining to) we drop the combining form vowel o. Following rule 4, the preAx intra- (meaning within) is at the beginning of the medical term with no combining form vowel used.  Language Rules for Building Medical Terms Intra/ven/ous – Pertaining to within the vein or Pertaining to within a vein. ◦ Following rule 5, no6ce that I start with the su3x -ous (that means pertaining to) then we work leV to right star6ng with the preAx Intra- (meaning within) and the combining form ven/o (meaning vein).  Medical Language Within the Context of Anatomy and Physiology Compare and contrast anatomy and physiology, including their specializa6ons and methods of study Discuss the fundamental rela6onship between anatomy and physiology Introduc(on to the Field Anatomy studies structures Gross Anatomy Microscopic Anatomy Regional Anatomy Systemic Anatomy Physiology studies the chemistry Anatomy focuses on structure and physiology focuses on function. Much of the study of physiology centers on the body’s tendency toward homeostasis. Structural Organization of the Human Body: Objectives Describe the structure of the human body in terms of six levels of organization List the eleven organ systems of the human body and identify at least one organ and one major function of each The Levels of Organization Lets discuss each level in brief  Organ Systems Basic functions of each Organ Systems cont.. Basic functions of each  Demonstrate the anatomical posi6on Describe the human body using direc6onal and regional terms Anatomical Terminology: Iden6fy three planes most commonly used in the study of anatomy Objec(ves Dis6nguish between the posterior and anterior body cavi6es, iden6fying their subdivisions and representa6ve organs found in each Describe serous membrane and explain its func6on Anatomical Posi(on Prone Supine Direc(onal Terms Essen6al for describing rela6ve loca6ons. Anatomical Planes Three most commonly used planes. Body Cavities Dorsal and Ventral are largest Representa6ve organs Abdominal Regions and Quadrants Help provide clear communica6on Serous Membranes Covers walls and organs in thoracic cavity. Pleura Pericardium Peritoneum  Growth (increase in size by increase cell number or size) Movement (action cause a change of position) Nutrition (organic substance or mineral ions) Func(ons of Life “Maintaining life Excretion (e.g., removal of toxic substances) in humans”: Reproduction (processes make more from same organism) Sensitivity ( e.g., ability to detect change in the environment stimuli) Respiration (breaking nutrient molecules to release energy)  Homeostasis  Homeostasis refers to a rela6vely stable set of condi6ons within an organism’s internal environment.  Within the human body, maintaining a healthy environment for living cells requires maintaining appropriate condi6ons in the extracellular Wuids – including the inters((al Wuid and blood plasma for each living cell to be able to func6on properly.  The constancy of an internal environment is important in allowing chemical reac6ons to take place at rates necessary to maintain the body. Maintaining homeostasis requires that the body con6nuously monitor its internal condi6ons. From body temperature to blood pressure to levels of certain nutrients, each physiological condi6on has a par6cular set point. Nega(ve Feedback Think of a thermostat Examples in the body. Posi(ve Feedback Childbirth Other examples?  Reference You are required to use this reference to revise and update your knowledge regarding medial terminology, anatomy, and physiology. Anatomy, Physiology and Medical Language h"ps://pressbooks.nscc.ca/medicallanguage/ Pages: (1 to 36) Pages: (91 to 94) Pages: (166-172)