Health Records

Ashworth University
Norcross, Georgia, United States

Course Format: Classroom | E-learning | Virtual Class | Online | On-site | Blended | Self-paced

Course Description:

'' The Health Records Course is comprised of 9 comprehensive lessons. They are easy to follow, yet challenging and stimulating at the same time. Each lesson begins with a subject matter preview and objectives, an introductory note from your instructor and a vocabulary builder of new words and terms.

Next comes the reading assignment. Practice exercises help you check and review what you’ve learned. At the end of the lesson is an open-book exam, which you may take online.

Lesson Descriptions ::
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.

Time Management Guide. How to improve your efficiency and productivity as a student and later in your health records career.

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.

...''

Phone:1.800.957.5412

School Address:

Ashworth University
430 Technology Parkway
Norcross, Georgia 30092
USA

Jobs & Resumes: Norcross
Houses & Roommates: Norcross

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