NOTICE TO ALL PROSPECTIVE HEALTH INFORMATION TECHNOLOGY STUDENTS:
11. Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities
Coding professionals shall:
11.1 Act in an honest manner and bring honor to self, peers, and the profession.
11.2 Truthfully and accurately represent their credentials, professional education, and experience.
11.3 Demonstrate ethical principles and professionals values in their actions to patients, employers, other members of the healthcare team, consumers, and other stakeholders served by the healthcare data they collect and report.
Copyright ©2012 by the American Health Information Management Association. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, photocopying, recording or otherwise without prior permission from the publisher.
ATTACHMENTS
Attached to this handbook are forms which must be completed. Please follow the instructions for each carefully.
• Immunization Form – This is to be completed by health care provider or health department
• Physical Examination Form – This is to be completed by health care provider
• Confidentiality Agreement for Students – This is to be completed by the student and returned at the end of orientation
• Clinical Student Disclosure Statement – This is to be completed by the student and returned at the end of orientation
• Receipt and Understanding of SC4 HIT Program Student Handbook – This is to be completed by the student and returned at the end of orientation
• Student Information Form – This is to be completed by the student and returned at the end of orientation
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• Release of Information Form – this is to be completed by the student and returned at the end of orientation
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St. Clair County Community College Health Information Technology
Student Health Data Sheet Immunization Form
Measles (Rubeola)
Date of Vaccination or Serum
Collection Serum Antibody
Result Two (2) doses of measles vaccine on
or after their first birthday and at least 30 days apart OR
Dose #1: ________________________
Dose #2: ________________________
Serologic test positive for measles antibody
Mumps One dose of mumps vaccine on or
after their first birthday OR Serologic test positive mumps antibody
Rubella One dose of Rubella vaccine on or
after their first birthday OR Serologic test positive for Rubella antibody
Hepatitis B
Date of Vaccination or Serum
Collection Serum Antibody
Result The minimum interval between the first
two (2) doses is four (4) weeks, and the minimum interval between the second and third doses is eight (8) weeks.
However, the first and third doses should be separated by no less than 16 (sixteen) weeks. It is not necessary to restart the series or add doses because of an extended interval between doses. OR
Dose #1: _______________________
Dose #2: _______________________
Dose #3: _______________________
Serologic test positive for Hepatitis B antibody
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Diphtheria - Tetanus – A cellular Pertussis (Tdap)
Date of Vaccination or Serum Collection One dose within past 10 (ten) years
Varicella
Date of Vaccination or Serum
Collection Serum Antibody
Result Two (2) doses of Varicella vaccine
administered four (4) to eight (8) weeks
apart OR Dose #1: ________________________
Dose #2: ________________________
Serologic test positive for Varicella antibody
Influenza
Date of Vaccination or Declination*
One dose annually
*If student declines, please attach a copy of declination form.
Healthcare Provider Information Printed Name:
Address: Phone Number:
Signature: Date:
Attention students: Please note this information is to be returned to the Health Information Technology administration offices, where it will be held in the strictest confidence. It is to be used for administrative purposes only, and will not be released without your written consent or knowledge.
Page 2 – Immunization Form
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St. Clair County Community College Health Information Technology
Student Health Data Sheet Physical Examination Form
Student Information
Student Name: Date of Birth:
Phone: SC4 Student Number:
General Information
Gender Height
(inches) Weight (lbs.) Blood Pressure Pulse
Male Female skin test within the past 90 (ninety) days prior to TSPOT) within the past 90 (ninety) days prior to beginning externship
OR If a prior positive reactor to skin testing, a negative chest x-ray within five (5) years and free of productive cough, night sweats, or unexplained loss of weight.
*If test #1 is negative, repeat in one (1) to three (3) weeks.
Drug Screen
Date of Screen Results
Ten (10) panel urine drug screen to be completed no earlier than six (6) weeks prior to start of externship.
Results must be submitted to the HIT Department prior to start of externship.
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Health Requirements
As best as can be determined by this examination, does the student have the ability to do the following?
Ability Yes No Comments/Observations
Student has the ability to distinguish and replicate alphanumeric text for accurate data entry.
Student has the ability to independently lift 20 pounds.
Student has the ability to maintain proper body mechanics by bending at the knees while keeping back straight.
Student has the ability to stand for two (2) hours without sitting.
Student possesses the gross and fine motor skills sufficient to operate computer equipment and adding machine.
Student communicates consistently and appropriately by listening, verbal and non-verbal methods.
Student possesses the emotional stability to perceive and deal appropriately with environmental stresses.
Page 2 – Physical Examination Form
Immunizations
Please complete the accompanying Immunization Data Sheet and return to student along with this form.
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Physician Narrative
Please note any findings you feel may inhibit the student’s ability to participate in the Health Information Technology program, or the ability to perform externships at various healthcare facilities.
Physician, Physician’s Assistant or Nurse Practitioner Information Printed Name:
Address: Phone Number:
Signature: Date:
Attention students: Please note this information is to be returned to the Health Information Technology administration offices, where it will be held in the strictest confidence. It is to be used for administrative purposes only, and will not be released without your written consent or knowledge.
Page 3 – Physical Examination Form
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St. Clair County Community College Health Information Technology Confidentiality Agreement for Students
As a student of the St. Clair County Community College (SC4) Health Information Technology (HIT) program, I understand that I will come in contact with various types of information during the execution of my academic studies. This information will include, but is not limited to, medical information, financial, information and business operations information. Some of this information is made confidential by law, such as ‘protected health information’ or ‘PHI’ under the federal Health Insurance Portability and Accountability Act, by SC4 policies or by Professional Practice Externship site policies. This confidential information may be in any form, e.g., written, electronic, oral, overheard or observed. I also understand that access to all confidential information is granted on a need-to-know basis. A need-to-know basis is defined as information access that is required in order to complete the HIT program requirements.
I agree that I will not share any confidential information, including PHI, with anyone, including fellow students. I further agree that I will not remove any confidential information, including PHI, from any professional practice site.
If I knowingly violate this agreement, I will be subject to possible dismissal from the SC4 HIT program, as well as possible criminal and civil prosecution under federal law.
I further understand if I witness any violation of this agreement by another SC4 HIT student, I will immediately notify the Director of the HIT program. If I fail to do so, I will be considered equally responsible for the violation.
I have read, understand and agree to the above. I understand signing this agreement and complying with its terms is a requirement for my continued admission to the SC4 HIT program.
______________________________________________________ __________________________
Student Name (print) Student Number
______________________________________________________ __________________________
Signature Date
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Criminal Background Check
Mandatory Exclusions for Specified Time Periods
In order to be granted clinical privileges at any of the covered facilities, 15 years must have lapsed since the individual completed all the terms and conditions of sentencing, parole and probation for conviction of the following offenses:
• Felony that involves the intent to cause death or serious impairment of a bodily function, that result in death or serious impairment of the bodily function that involves the use of force or violence or that involves the threat or the use of force or violence. This includes:
- Homicide
- Assault and infliction of serious injury - Assault with intent to commit murder
- Assault with intent to do great bodily harm less than murder - Assault with intent to maim
- Attempt to murder
• Felony involving cruelty or torture.
• Felony of crime committed against “vulnerable adults” who because of age, developmental disability, mental illness or physical disability, require supervision or personal care or lack the personal and social skills required to live independently.
• Felony involving criminal sexual conduct.
• Felony involving abuse or neglect generally related to vulnerable adults or children which typically results in serious physical or mental harm to the vulnerable adult.
• Felony involving the use of a firearm or dangerous weapon.
• Felony involving the diversion or adulteration of a prescription drug or other medications.
In order to be granted clinical privileges at any of the covered facilities, 10 years must have lapsed since the individual completed all the terms and conditions of sentencing, parole and probation for conviction of the following offenses:
• Misdemeanor involving the use of a firearm or dangerous weapon with the intent to injure, the use of a firearm or dangerous weapon that results in a personal injury, or a misdemeanor involving the use of force or violence or the threat of the use of force or violence.
• Misdemeanor crime committed against “vulnerable adults”.
• Misdemeanor involving criminal sexual conduct which involve instances of sexual contact with another person that does not involve sexual penetration and are typically known as “fourth degree criminal sexual conduct”.
• Misdemeanor involving cruelty or torture (usually first conviction regarding animals).
• Misdemeanor involving abuse or neglect in the third or fourth degree if the caregiver intentionally or recklessly causes “physical harm” to a vulnerable adult.
• Third Driving Under the Influence (DUI) conviction.
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In order to be granted clinical privileges at any of the covered facilities, 5 years must have lapsed since the individual completed all the terms and conditions of sentencing, parole and probation for conviction of the following offenses:
• Misdemeanor involving cruelty if committed by an individual who is less than 16 years of age including cruel treatment of animals.
• Misdemeanor involving home invasion that typically is described as “breaking and entering” into another person’s home.
• Misdemeanor involving embezzlement which is a person who has taken money from another person who had entrusted the money with the wrongdoer, e.g. a store cashier.
• Misdemeanor involving negligent homicide which is committed when a person engages in careless or reckless driving that causes death.
• Misdemeanor involving larceny which is legally described as the act of stealing but it does not include shoplifting. An example would be theft from a building of an item that is not offered for sale.
• Misdemeanor of retail fraud in the second degree which involves shoplifting property from a store that is offered for sale at a price of $200 or more but less than $1,000 or less than $200 if the person has been previously convicted of any crime or theft.
• Any other misdemeanor involving assault, fraud, theft, or the possession or delivery of a controlled substance unless otherwise provided for under other subsections.
In order to be granted clinical privileges at any of the covered facilities, 3 years must have lapsed since the individual completed all the terms and conditions of sentencing, parole and probation for conviction of the following offenses:
• Misdemeanor for assault which is defined as the individual attempting or threatening to hurt another.
• Misdemeanor of retail fraud in the third degree which involved shoplifting property from a store that is offered for sale at a price of less than $200.
• Misdemeanor involving the creation, delivery or possession with intent to manufacture or deliver a controlled substance.
An individual cannot be granted clinical privileges at any of the covered facilities if within the year immediately preceding the date of application for employment or clinical privileges the individual was convicted of the following offenses:
• Misdemeanor involving the creation, delivery or possession with intent to manufacture or deliver a controlled substance if the individual, at the time of conviction, is under the age of 18.
• Misdemeanor for larceny or retail fraud in the second or third degree which involved shoplifting property from a store that is offered for sale at a price of less than $200 if the individual, at the time of conviction, is under the age of 16.
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Permanent Exclusions:
• If the individual has ever pleaded “not guilty by reason of insanity” and that plea has been entered in the law enforcement information network (LEIN), the individual cannot work in long-term care.
• If the individual has ever been the subject of a substantiated finding of neglect, abuse or misappropriation of property by a state or federal agency, the individual cannot work in long-term care. For example, an individual would be excluded if their nurse aide certification was “flagged”.
Clarifications on Legal Terminology
1 Criminal Sexual Conduct Misdemeanor: Fourth Degree Criminal Sexual Conduct Felony: First, Second and Third Degree Criminal Sexual Conduct
2 Cruelty and Torture to Animals Misdemeanor: First Offense Felony: More than one offense
3 DUI Convictions
Misdemeanor: Does not exclude individual from working in long-term care
Felony: Third DUI conviction. This felony requires 10 year exclusionary period between the Student’s discharge from state supervision to the date of the employment application or granting of clinical privileges.
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To be Retained by the Educational Institution
Student Name: _________________________________________________________ Date: __________________________
Educational Institution Name: __________________________________ Training Program: __________________________
1. I certify that I have not been convicted of a crime or offense that prohibits me from being granted clinical privileges in a long-term care setting as required by P.A. 27, 28 and 29 of 2006 within the applicable time period prescribed by each crime.
______________________________________________________________ _______________________________
Signature of Student Date
2. I certify that I have not been the subject of an order or disposition under the Code of Criminal Procedure dealing with findings of “not guilty by reason of insanity” for any crime.
______________________________________________________________ _______________________________
Signature of Student Date
3. I certify that I have not been the subject of a state or federal agency substantiated finding of patient or resident neglect, abuse or misappropriation of property or any activity that caused my nurse aide certification to be “flagged.”
______________________________________________________________ _______________________________
Signature of Student Date
4. I have listed below all offenses for which I have been convicted, including all terms and conditions of sentencing, parole and probation and any substantiated finding of patient or resident neglect, abuse or misappropriation of property.
______________________________________________________________ _______________________________
Signature of Student Date
Conviction/Offense Date of
Conviction/Offense City State Sentence Date of
Discharge
5. I certify that I have reviewed the list of prohibited offenses as defined in P.A. 27, 28 and 29, and that the above list of my convictions and/or substantiated findings of patient or resident neglect, abuse or misappropriation of property (if any) is true, correct and complete to the best of ny knowledge. I also understand that if the information is not accurate or complete, my clinical privileges will be withdrawn immediately. I understand that the facility or education program denying my privileges based on information retained through a background check is provided immunity from any action brought by a Student due to the decision to remove clinical privileges.
______________________________________________________________ _______________________________
Signature of Student Date
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Student Information Form Demographic Information
Name (L, F, MI) Student ID Number: Date:
Residential Street Address:
Residential City: Residential State: Residential Zip Code:
Mailing Address (PO Box, Rural Route):
Mailing City: Mailing State: Mailing Zip Code:
Home Phone: Work Phone: Cell Phone:
SC4 Email Address: Personal Email Address:
Academic History
High School GED Or
Did you graduate?
Yes No
Name and Address of School: Dates of Attendance:
_________________________
To
_________________________
Major:
Vocational
School Did you graduate?
Yes No
Name and Address of School: Dates of Attendance:
_________________________
Name and Address of School: Dates of Attendance:
_________________________
Name and Address of School: Dates of Attendance:
_________________________
To
_________________________
Major:
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Credentials: Accrediting Body: Date First Granted: Expiration Date:
Credentials: Accrediting Body: Date First Granted: Expiration Date:
Credentials: Accrediting Body: Date First Granted: Expiration Date:
Healthcare Experience
Externship/Vocational
Training Yes No
Name and Address of Facility: Dates of Service:
_________________________
To
_________________________
Volunteer Yes No
Name and Address of Facility: Dates of Service:
_________________________
To
_________________________
Work Yes No
Name and Address of Facility: Dates of Service:
_________________________
To
_________________________
What do you perceive to be the major responsibilities of a Health Information Technology professional? (Please answer below)
__________________________________________________________
Student Name (Last, First, MI)
66 | P a g e What influenced your decision to pursue Health Information Technology and why do you feel you are suited to the profession? (Please answer below)
List your strengths and explain how they will assist you in achieving your education and career goals. (Please answer below)
__________________________________________________________
Student Name (Last, First, MI)
67 | P a g e List any weaknesses you fell might hinder your educational/professional growth and what you intend to do to improve in these areas. Please address how SC4 HIT staff and faculty can assist you. (Please answer below)
What are your career goals following graduation from the SC4 HIT program? (Please answer below)
Do you intend to further your education following graduation from the SC4 HIT program? If so, please indicate what level you intend to complete. (Please answer below)
Yes No Bachelor’s Degree Master’s Degree PhD
__________________________________________________________
Student Name (Last, First, MI)
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St. Clair County Community College Health Information Technology Program
Release of Information Form
I, ______________________________________________, do hereby authorize the St. Clair County Community College Health Information Technology Program administration to release the following information to any professional practice site(s) to which I am assigned:
• Criminal Background Check results
• FBI Fingerprinting results
• Physical Examination results
• Laboratory Testing results
• Drug Testing results
• Proof of Immunizations
• Proof of Health Insurance Portability and Accessibility Act training
• Proof of Universal Precaution and Bloodborne Pathogen training
• Proof of Professional Liability Insurance Coverage
• Date of Birth
• Last four (4) digits of Social Security Number Please initial each of the following statements after reading:
__________ I understand that this form may be revoked at any time, providing that the information has not been already disclosed. I further understand that in revoking this form, I may hinder the ability for St. Clair County Community College Health Information Technology Program staff to place me in a professional practice externship, therefore making graduation from the program impossible.
__________ I may only revoke this authorization by notifying, in writing, the St. Clair County Community College Health Information Technology Program administration.
__________ I understand that this authorization will expire when I am no longer enrolled in the St. Clair County Community College Health Information Technology Program.
__________________________________________________________________ _______________________________
Student Name (printed) Student Number
__________________________________________________________________ _______________________________
Student Signature Date
__________________________________________________________________ _______________________________
Witness Signature Date
__________________________________________________________________
Witness Name (printed)
69 | P a g e Receipt and Understanding of
St. Clair County Community College Health Information Technology Program Student Handbook Signature Form
I have received a copy of the Health Information Technology Program at St. Clair County Community College. I have read and agree to the following (initial by each after reading):
__________ I understand and agree to abide by the policies set forth in this handbook, as well as the policies in the St. Clair County Community College Catalogue and Student Handbook.
__________ I have read the summary from the Public Health Code and understand the reasons for which St. Clair County Community College may deny me a placement in a professional practice externship.
__________ I have read, understand and agree to a criminal background check and FBI fingerprinting. I understand I will not be placed in a professional practice externship until such time this is completed.
__________ I have read, understand and agree to a criminal background check and FBI fingerprinting. I understand I will not be placed in a professional practice externship until such time this is completed.