||This course is a study of the basic health information systems, both paper-based and electronic, with an emphasis on electronic. Primary and secondary records will be defined. Other areas to be covered are basic documentation requirements and the management of paper records. An introduction to classification systems, taxonomies, nomenclatures, terminologies and clinical vocabularies is provided. An electronic health record (EHR) educational system is used extensively in this course as a foundation for EHR utilization throughout a health care organization.
- Define data elements of health records, indices and registries.
- Define documentation requirements.
- Compare manual and electronic record processing.
- Examine different health information media such as paper, hybrid and electronic.
- Define primary and secondary health records.
- Identify and use secondary data sources.
- Validate the reliability and accuracy of secondary data sources.
- Utilize electronic systems for patient registration, ADT (admission, discharge, transfer), record tracking and deficiency analysis.
- Explain the different classification systems, taxonomies, nomenclatures, terminologies and clinical vocabularies.
- Comply with ethical standards of practice.
- Apply knowledge of alphabetical and terminal digit filing systems.
- Perform documentation in an electronic health record.
- Discuss the history of electronic health records and the impact on patient care.
- Define documentation requirements in a patient record.
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