Medical Records and Health Information Management
The record is a legal document, a clinical tool and a data asset. Manage it as all three.
Program overview
Health information management is subsumed almost everywhere into coding training, leaving the discipline itself unserved. This course restores it: record structure and content standards, the legal status of the clinical record, retention and destruction, release of information and who may authorise it, master patient index integrity and duplicate resolution, data quality auditing, and the transition from paper to electronic and hybrid records. It covers both the operational work and the governance obligations that sit on top of it.
Why this program
Restores a discipline usually absorbed into coding
Covers legal status, retention and release properly
Includes master patient index integrity
Addresses hybrid paper-electronic reality
Who it is for
Program objectives
- Describe the required structure and content standards of a clinical record
- Explain the legal status of the health record and its implications
- Apply retention, archiving and destruction rules correctly
- Process a release of information request lawfully
- Maintain master patient index integrity and resolve duplicates
- Audit record quality against defined criteria
Learning outcomes
- Evaluate a described record entry against content standards
- Apply retention rules to a specified record type
- Process a described release of information request correctly
- Identify the risks created by a duplicate patient record
- Design a record quality audit for a stated concern
- Differentiate correction, amendment and addendum in a clinical record
Curriculum
Module 1: The Record and Its Purposes
1 lessonsThe Record and Its PurposesPreview
Clinical, legal, financial and secondary uses.
Module 2: Content and Structure Standards
1 lessons- Content and Structure Standards
Module 3: Retention, Archiving and Destruction
1 lessons- Retention, Archiving and Destruction
Module 4: Release of Information
1 lessons- Release of Information
Module 5: Identity and Data Quality
1 lessons- Identity and Data Quality
Duration and structure
5 lessons across 5 modules. Duration is expressed in study hours.
What you receive
This certificate confirms completion of Medical Records and Health Information Management. Duration is expressed in study hours.
Delivery format
- Self-paced — start any time.
- Study on any device.
- Lifetime access to the version you enrolled in.