Health Records

Lesson 1: Basic Medical Terminology. An introduction to fundamental word elements and word combinations relevant to basic medical and dental terminology; common medical and anatomical vocabulary; specialization areas of the medical profession; common departments and their primary functions in the typical hospital or health facility.

Lesson 2: HIPAA, the Patient Chart and the Release of Patient Information. The layout and organization of the patient chart; the impact of the Health Insurance Portability and Accountability Act (HIPAA) on the use and disclosure of personal health information; compliance regulations pertaining to healthcare providers that are the responsibility of Health Records Specialists.

Lesson 3: Health Insurance Carriers and Claims. The major medical insurance programs; procedural and diagnostic coding; procedures for filling out and filing insurance claim forms; types of patient information requested by health insurance carriers for determining coverage and medical necessity; information required to support health insurance claims submitted by providers.

Lesson 4: Electronic Medical Record Systems. Replacing paper-based charts with electronic medical record systems (EMR); computerized optical scanning and storage systems to replace microfilm and microfiche systems.

Lesson 5: The Health Information Management Department. The role of the health records clerk; job functions; career opportunities; functions of the health information management department – including storage and retrieval, release of information, coding, corporate compliance and abstracting; assembling the medical record; transcription; the cancer registry; risk management.

Lesson 6: Filing Methods and Medical Record Processing. Alphabetic filing; numeric filing; digit filing; unit and serial numbering; color coding; outguides; filing loose documents; step-by-step filing procedure for filing a record using terminal digit filing; batch filing; master patient index and file errors; computerized master patient indexes; admission and discharge processing; record retrieval; procedure for locating misfiles.

Lesson 7: The Assembly and Contents of the Medical Record. Medical records documents; the face sheet; signature profile; discharge summary; coding summary; physician orders; history and physical; consultation reports; progress notes; critical care/second visit notes; laboratory test results; cancer, pathology, radiology and procedure/operative reports; anesthesia documentation; operating room and clinical record; filing surgical documents; nursing documentation; ancillary reports; consents; record of death; autopsy report; transfer record; OB/newborn record; rehabilitation records; psychiatric records; permanent dividers.

Lesson 8: Medical Record Analysis and the Physician Incomplete Area. Completion requirements; history and physical; consultation reports; discharge summary; test results; orders and progress notes; anesthesia records; nursing and ancillary services records; deficiency slips; physician notification procedure; incomplete record filing; pulling records for physician completion; physician incomplete area; working with physicians; reporting problems; updating files after completion; computerized deficiency slip; final check; record filed incomplete; delinquent record statistics.

Lesson 9: Protecting Patient Confidentiality and Other Functions of the Medical Records Clerk. Confidentiality of the medical record; release without patient consent; release requiring patient consent; Federal Privacy Act of 1974; confidentiality of substance abuse treatment records; Health Insurance Portability and Accountability Act (HIPAA); confidentiality of psychiatric records; patient access to records; release of information; procedure for processing mail requests; processing birth certificates; newborn test results; health records functions of the transcription clerk, case management clerk, cancer registry clerk, outpatient clinic clerk, and optical imaging clerk.