PUB370 Practical Clinical Classification
To view more information for this unit, select Unit Outline from the list below. Please note the teaching period for which the Unit Outline is relevant.
| Unit code: | PUB370 |
|---|---|
| Prerequisite(s): | PUB359 and PUB202 |
| Credit points: | 12 |
| Timetable | Details in HiQ, if available |
| Availabilities |
|
| CSP student contribution | $1,118 |
| Domestic tuition unit fee | $4,104 |
| International unit fee | $4,488 |
Unit Outline: Semester 2 2024, Kelvin Grove, Internal
| Unit code: | PUB370 |
|---|---|
| Credit points: | 12 |
| Pre-requisite: | PUB359 and PUB202 |
| Coordinator: | Maryann Wood | mt.wood@qut.edu.au |
Overview
As a Health Information Manager, it is essential to thoroughly understand clinical coding to support Activity Based Funding and casemix systems. This unit will provide students with greater competence and confidence in the use of the International Classification of Disease 10th revision Australian modification, the Australian Classification of Health Interventions and the Australian Coding Standards. Through hospital based placements, students will code from digital and/or paper based medical records and utilise IT feeder systems to support their coding decisions. Advancement of coding quality processes and techniques will also be covered. Students will identify the relationship between coding and activity based funding through analysis of assigned diagnosis related groups. This final semester unit builds on the introductory and Advanced clinical classification units studied in previous years and will assist the graduate in being ready for employment in a clinical coding role.
This is a designated unit which is essential to your course progression. Designated units include professional experience units, units requiring the development of particular skills, and units requiring demonstration of certain personal qualities. If you fail to achieve a satisfactory level of performance in a designated unit, you may be excluded from enrolment or will be put on academic probation. If you fail a designated unit twice within your course, you may be excluded. Supplementary assessment is not available on designated units.
Learning Outcomes
On successful completion of this unit you will be able to:
- Utilise all sources of clinical data to assign codes
- Interpret and use the Australian Coding Standards in complex clinical scenarios
- Implement the requirements for ABF reporting
- Develop, implement and evaluate coding quality processes
Content
This unit consists of the following major areas of study:
- general principles of clinical documentation, including exploration of documentation quality issues, appropriate interpretation of relevant documents and need for coding queries
- interpretation of the relationship between codes assigned and the diagnosis related groups applied
- access to needed data to inform coding decisions from various IT feeder systems
- application of Australian Coding Standards to complex cases, such as high cost DRGs and adverse events
- experience using coding quality tools and techniques
- how coded data is used for funding and reporting purposes
Learning Approaches
This unit focusses on integrating the practical and theoretical aspects of clinical classification practice. You will engage in experiential learning strategies in the health facility setting. The unit is designed to provide practical application of coding techniques in a work integrated learning environment. Students will be supported by hospital coders and will code from either paper based or digital medical records or a combination of both. Students will also engage with academic staff through online support sessions during the semester.
Feedback on Learning and Assessment
Formative
You will receive regular feedback and support from academic staff and your placement supervisors, aimed at identifying strengths and opportunities for improvement. It is also expected that you will demonstrate self-assessment and identification of learning needs as you encounter unfamiliar coding issues.
Summative
You will submit two reports relating to coding activities and experiences during the semester. You will also complete a coding quality activity and produce a report on your findings. Feedback on these documents will constitute your summative assessment.
Assessment
Overview
Assessment will comprise two assessment items. This unit will normally be undertaken in the final semester with PUB371 Transition to Professional Health Information Practice and PUB373 Integrated Health Information Management Practice and the three units will involve a combined total of 4 days x 12 weeks (or equivalent depending on student placement plans) of work-integrated learning in a health care facility. In the part-time mode this unit will be undertaken in the same semester as PUB371 Transition to Professional Health Information Practice and will involve a combined total of 2 days x 12 weeks (or equivalent depending on student placement plans) of placement attendance.
Unit Grading Scheme
7- point scale
Assessment Tasks
Assessment: Practical Coding
This assessment item is designed to develop competence and confidence in advanced clinical classification through analysis and coding of real world health records and the diagnosis related group assigned to each case. A minimum of 12 days across the semester will be spent coding and assessing the quality of medical records during the placement. Two reports relating to your coding activity will be submitted during the semester in weeks 6 and 12 (or equivalent depending on student placement plans) of your placement period. The assessment item contributes to developing skills and knowledge for career development and employability.
This assignment is eligible for the 48-hour late submission period and assignment extensions.
Assessment: Report
This assessment item is designed to gauge knowledge and understanding of coding quality concepts through the identification of a coding quality issue, research of an appropriate tool for assessing that issue, implementation of the assessment tool, analysis and interpretation of the results and compilation of a report. The assessment item is authentic as it mirrors the work conducted in practice including compiling information into a real world report for submission to an organisation.
This assignment is eligible for the 48-hour late submission period and assignment extensions.
Academic Integrity
Students are expected to engage in learning and assessment at QUT with honesty, transparency and fairness. Maintaining academic integrity means upholding these principles and demonstrating valuable professional capabilities based on ethical foundations.
Failure to maintain academic integrity can take many forms. It includes cheating in examinations, plagiarism, self-plagiarism, collusion, and submitting an assessment item completed by another person (e.g. contract cheating). It can also include providing your assessment to another entity, such as to a person or website.
You are encouraged to make use of QUT’s learning support services, resources and tools to assure the academic integrity of your assessment. This includes the use of text matching software that may be available to assist with self-assessing your academic integrity as part of the assessment submission process.
Further details of QUT’s approach to academic integrity are outlined in the Academic integrity policy and the Student Code of Conduct. Breaching QUT’s Academic integrity policy is regarded as student misconduct and can lead to the imposition of penalties ranging from a grade reduction to exclusion from QUT.
Requirements to Study
Requirements
Hepatitis B, COVID-19, Measles, Mumps, Rubella, Varicella, and Pertussis vaccinations, blue card
HIM Placement T-shirt
Criminal history check
Students who are required to undertake placements off campus may incur additional costs (for example travel and accommodation).
Blue Card
A blue card is required to complete this unit. A blue card confirms that you have passed a screening of your criminal history (the Working with Children Check) and have been approved to work with children and young people. For more information on the blue card and how to apply please visit the QUT website.
Costs
There is a cost for vaccinations and the criminal history check.
Students who are required to undertake placements off campus may incur additional costs (for example travel and accommodation).
Resources
There is no prescribed text for this unit.
Resource Materials
Prescribed text(s)
HIMAA. (2021). The Australian dictionary of clinical abbreviations, acronyms & symbols. (8th Edition). Sydney: HIMAA.
Risk Assessment Statement
WORKPLACE HEALTH AND SAFETY ISSUES
Placement agencies are covered by their own Workplace Health and Safety requirements and
policies. Details of these are outlined in their agency profile held by the School.
During your placement you are required to conduct yourself in a safe and professional
manner, avoiding any risk taking behaviours.
The University's student insurance policy specifically covers the range of activity included in the professional practice placement.
You will be required to obtain a valid Blue Card (Working with Children Check) and demonstrate vaccination compliance before
commencing field placement.
INSURANCE COVER
The University has taken out personal accident insurance to cover students engaged in work
experience programs. Students involved in professional practice are covered under the conditions of this scheme including cover under the University's legal liability policy, in the event of an action of negligence involving personal injury or property damage being brought against the University. Information will be forwarded to agencies involved in the professional practice program informing them of the QUT insurance cover.
The personal accident insurance cover provides cover for death or injury with capital benefits on a sliding scale up to $35,000 depending on the nature of the injury but does not provide for weekly or medical benefits. This policy has been taken out because students involved in work experience programs from the University are not eligible for normal workers' compensation cover.
The Student Guild has a separate insurance cover for injury to students. You can access this by contacting your Guild.
Course Learning Outcomes
This unit is designed to support your development of the following course/study area learning outcomes.PU51 Bachelor of Health Information Management
- Critically evaluate and apply theoretical and technical perspectives on health information management (HIM), applicable to professional practice to solve routine and emergent problems. [Knowledge, Practice]
Relates to: Practical Coding, Report - Initiate effective approaches for engaging in critical thinking, decision making and problem solving that reflect diverse perspectives and culturally safe and responsive practice, encompassing evidence-based HIM solutions. [Practice, Values/Disposition
Relates to: Practical Coding, Report - Employ digital capabilities in accessing, evaluating, utilising and communicating digital health information across a range of stakeholders, and intra- and inter-professional contexts that demonstrate independence, accountability, creativity and initiative as a HIM professional. [Practice, Values/Disposition]
Relates to: Practical Coding, Report - Exercise judgement in the context of HIM, informed by sustainable, legal, ethical, and professional perspectives that promote social inclusivity, multidisciplinary collaboration and reflective practice. [Values/Disposition, Knowledge, Practice]
Relates to: Practical Coding, Report - Reflect critically on performance and feedback to identify self improvements and action learning opportunities, while building productive professional relationships across diverse stakeholders. [Practice, Values/Disposition]
Relates to: Practical Coding, Report
Unit Outline: Semester 2 2024, Online
| Unit code: | PUB370 |
|---|---|
| Credit points: | 12 |
| Pre-requisite: | PUB359 and PUB202 |
Overview
As a Health Information Manager, it is essential to thoroughly understand clinical coding to support Activity Based Funding and casemix systems. This unit will provide students with greater competence and confidence in the use of the International Classification of Disease 10th revision Australian modification, the Australian Classification of Health Interventions and the Australian Coding Standards. Through hospital based placements, students will code from digital and/or paper based medical records and utilise IT feeder systems to support their coding decisions. Advancement of coding quality processes and techniques will also be covered. Students will identify the relationship between coding and activity based funding through analysis of assigned diagnosis related groups. This final semester unit builds on the introductory and Advanced clinical classification units studied in previous years and will assist the graduate in being ready for employment in a clinical coding role.
This is a designated unit which is essential to your course progression. Designated units include professional experience units, units requiring the development of particular skills, and units requiring demonstration of certain personal qualities. If you fail to achieve a satisfactory level of performance in a designated unit, you may be excluded from enrolment or will be put on academic probation. If you fail a designated unit twice within your course, you may be excluded. Supplementary assessment is not available on designated units.
Learning Outcomes
On successful completion of this unit you will be able to:
- Utilise all sources of clinical data to assign codes
- Interpret and use the Australian Coding Standards in complex clinical scenarios
- Implement the requirements for ABF reporting
- Develop, implement and evaluate coding quality processes
Content
This unit consists of the following major areas of study:
- general principles of clinical documentation, including exploration of documentation quality issues, appropriate interpretation of relevant documents and need for coding queries
- interpretation of the relationship between codes assigned and the diagnosis related groups applied
- access to needed data to inform coding decisions from various IT feeder systems
- application of Australian Coding Standards to complex cases, such as high cost DRGs and adverse events
- experience using coding quality tools and techniques
- how coded data is used for funding and reporting purposes
Learning Approaches
This unit focusses on integrating the practical and theoretical aspects of clinical classification practice. You will engage in experiential learning strategies in the health facility setting. The unit is designed to provide practical application of coding techniques in a work integrated learning environment. Students will be supported by hospital coders and will code from either paper based or digital medical records or a combination of both. Students will also engage with academic staff through online support sessions during the semester.
Feedback on Learning and Assessment
Formative
You will receive regular feedback and support from academic staff and your placement supervisors, aimed at identifying strengths and opportunities for improvement. It is also expected that you will demonstrate self-assessment and identification of learning needs as you encounter unfamiliar coding issues.
Summative
You will submit two reports relating to coding activities and experiences during the semester. You will also complete a coding quality activity and produce a report on your findings. Feedback on these documents will constitute your summative assessment.
Assessment
Overview
Assessment will comprise two assessment items. This unit will normally be undertaken in the final semester with PUB371 Transition to Professional Health Information Practice and PUB373 Integrated Health Information Management Practice and the three units will involve a combined total of 4 days x 12 weeks (or equivalent depending on student placement plans) of work-integrated learning in a health care facility. In the part-time mode this unit will be undertaken in the same semester as PUB371 Transition to Professional Health Information Practice and will involve a combined total of 2 days x 12 weeks (or equivalent depending on student placement plans) of placement attendance.
Unit Grading Scheme
7- point scale
Assessment Tasks
Assessment: Practical Coding
This assessment item is designed to develop competence and confidence in advanced clinical classification through analysis and coding of real world health records and the diagnosis related group assigned to each case. A minimum of 12 days across the semester will be spent coding and assessing the quality of medical records during the placement. Two reports relating to your coding activity will be submitted during the semester in weeks 6 and 12 (or equivalent depending on student placement plans) of your placement period. The assessment item contributes to developing skills and knowledge for career development and employability.
This assignment is eligible for the 48-hour late submission period and assignment extensions.
Assessment: Report
This assessment item is designed to gauge knowledge and understanding of coding quality concepts through the identification of a coding quality issue, research of an appropriate tool for assessing that issue, implementation of the assessment tool, analysis and interpretation of the results and compilation of a report. The assessment item is authentic as it mirrors the work conducted in practice including compiling information into a real world report for submission to an organisation.
This assignment is eligible for the 48-hour late submission period and assignment extensions.
Academic Integrity
Students are expected to engage in learning and assessment at QUT with honesty, transparency and fairness. Maintaining academic integrity means upholding these principles and demonstrating valuable professional capabilities based on ethical foundations.
Failure to maintain academic integrity can take many forms. It includes cheating in examinations, plagiarism, self-plagiarism, collusion, and submitting an assessment item completed by another person (e.g. contract cheating). It can also include providing your assessment to another entity, such as to a person or website.
You are encouraged to make use of QUT’s learning support services, resources and tools to assure the academic integrity of your assessment. This includes the use of text matching software that may be available to assist with self-assessing your academic integrity as part of the assessment submission process.
Further details of QUT’s approach to academic integrity are outlined in the Academic integrity policy and the Student Code of Conduct. Breaching QUT’s Academic integrity policy is regarded as student misconduct and can lead to the imposition of penalties ranging from a grade reduction to exclusion from QUT.
Requirements to Study
Requirements
Hepatitis B, COVID-19, Measles, Mumps, Rubella, Varicella, and Pertussis vaccinations, blue card
HIM Placement T-shirt
Criminal history check
Students who are required to undertake placements off campus may incur additional costs (for example travel and accommodation).
Blue Card
A blue card is required to complete this unit. A blue card confirms that you have passed a screening of your criminal history (the Working with Children Check) and have been approved to work with children and young people. For more information on the blue card and how to apply please visit the QUT website.
Costs
There is a cost for vaccinations and the criminal history check.
Students who are required to undertake placements off campus may incur additional costs (for example travel and accommodation).
Resources
There is no prescribed text for this unit.
Resource Materials
Prescribed text(s)
HIMAA. (2021). The Australian dictionary of clinical abbreviations, acronyms & symbols. (8th Edition). Sydney: HIMAA.
Risk Assessment Statement
WORKPLACE HEALTH AND SAFETY ISSUES
Placement agencies are covered by their own Workplace Health and Safety requirements and
policies. Details of these are outlined in their agency profile held by the School.
During your placement you are required to conduct yourself in a safe and professional
manner, avoiding any risk taking behaviours.
The University's student insurance policy specifically covers the range of activity included in the professional practice placement.
You will be required to obtain a valid Blue Card (Working with Children Check) and demonstrate vaccination compliance before
commencing field placement.
INSURANCE COVER
The University has taken out personal accident insurance to cover students engaged in work
experience programs. Students involved in professional practice are covered under the conditions of this scheme including cover under the University's legal liability policy, in the event of an action of negligence involving personal injury or property damage being brought against the University. Information will be forwarded to agencies involved in the professional practice program informing them of the QUT insurance cover.
The personal accident insurance cover provides cover for death or injury with capital benefits on a sliding scale up to $35,000 depending on the nature of the injury but does not provide for weekly or medical benefits. This policy has been taken out because students involved in work experience programs from the University are not eligible for normal workers' compensation cover.
The Student Guild has a separate insurance cover for injury to students. You can access this by contacting your Guild.
Course Learning Outcomes
This unit is designed to support your development of the following course/study area learning outcomes.PU51 Bachelor of Health Information Management
- Critically evaluate and apply theoretical and technical perspectives on health information management (HIM), applicable to professional practice to solve routine and emergent problems. [Knowledge, Practice]
Relates to: Practical Coding, Report - Initiate effective approaches for engaging in critical thinking, decision making and problem solving that reflect diverse perspectives and culturally safe and responsive practice, encompassing evidence-based HIM solutions. [Practice, Values/Disposition
Relates to: Practical Coding, Report - Employ digital capabilities in accessing, evaluating, utilising and communicating digital health information across a range of stakeholders, and intra- and inter-professional contexts that demonstrate independence, accountability, creativity and initiative as a HIM professional. [Practice, Values/Disposition]
Relates to: Practical Coding, Report - Exercise judgement in the context of HIM, informed by sustainable, legal, ethical, and professional perspectives that promote social inclusivity, multidisciplinary collaboration and reflective practice. [Values/Disposition, Knowledge, Practice]
Relates to: Practical Coding, Report - Reflect critically on performance and feedback to identify self improvements and action learning opportunities, while building productive professional relationships across diverse stakeholders. [Practice, Values/Disposition]
Relates to: Practical Coding, Report