Clinical Data Management: Applications and analysis of quality and clinical resources appropriate to the clinical setting to include database management, and coding compliance using CPT, ICD-9-CM, or other specialized coding systems within the prospective or payment system to ensure quality and cost effectiveness of the services rendered (for example, data integrity, quality of documentation, and clinical efficiency).
Clinical Foundations: Understanding of human anatomy and physiology, the nature of disease processes, and the protocols of diagnosis and treatment of the major diseases to include common drugs, laboratory, and other tests used for the diagnosis and treatment of disease. Practice the ability to apply this knowledge to the reading, coding, and abstracting of medical information to support quality patient care and associated databases.
ICD-10: ICD-10-CM/PCS application and use.
External Forces: The study of regulatory requirements and the development of appropriate compliance initiatives for policies, procedures, protocols, and technology for hospitals, specialty facilities, and other healthcare providers, which includes the development of systems (for example, e-HIM®) to implement required practices for the Joint Commission and other accrediting bodies, federal and state appropriate rules and regulations (that is, the Centers for Medicare and Medicaid Services, and the Health Insurance Portability and Accountability Act (HIPAA)).
Management Development: Application of organizational management theory and practices in addition to human resource management techniques to improve departmental adaptability, innovation, service quality, and operational efficiency.
Performance Improvement: Development and application of quality processes to ensure quality data is generating consistent and timely quality information, and to develop systems that are flexible and adaptable in a constantly changing healthcare environment (for example, e-HIM®, regulatory changes, and new technology).
Privacy and Security: Understanding and applying current healthcare regulations promoting protection of medical information and the electronic transmission of health information; and acting as the patient’s advocate for their understanding of their rights in regards to protected health information on any applicable analog or digital medium.
Technology: Application of existing and emerging technologies for the collection of clinical data, the transformation of clinical data to useful health information, and the communication and protection of information on an analog medium, (for example, paper, photographic film, and so on) or digital medium, (for example, magnetic tape, optical disk, CD, DVD, and so on).