Medical Records and Health Information Management

1. 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.

2. 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.

3. Who it is for

Medical Secretary · Healthcare Manager · Quality Officer · Nurse · Physician

4. 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

5. 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

6. Curriculum

1. Module 1: The Record and Its Purposes

   • The Record and Its Purposes

2. Module 2: Content and Structure Standards

   • Content and Structure Standards

3. Module 3: Retention, Archiving and Destruction

   • Retention, Archiving and Destruction

4. Module 4: Release of Information

   • Release of Information

5. Module 5: Identity and Data Quality

   • Identity and Data Quality

7. Duration and structure

Total study hours: 3.5 — 2.75h content + 0.75h assessment. Duration is expressed in study hours only.

9. What you receive

This certificate confirms completion of Medical Records and Health Information Management. Duration is expressed in study hours.

10. Delivery format

Self-paced · start any time · any device · lifetime access to the enrolled version.