HDIM 1350 - Documentation & Electronic Health Record

4.5 Credits

Students learn the importance of accurate and timely health record documentation, along with key requirements and principles across healthcare settings. Topics include information governance, electronic health records (EHR) and health IT, clinical documentation improvement, and federal and state regulations. Students also use an online simulated system to explore EHR components.

Note: Students must complete this course with a grade of C or better.

Corequisite: (1) HDIM 1010

Lecture Hours: 4.5
Lab Hours: 0.0
Internship Hours: 0.0
Clinical or Practicum Hours: 0.0

Course Objectives

Discuss the framework and history of the healthcare delivery system.
Explain the principal and ancillary functions of the healthcare record.
Summarize the importance of statistical reporting and public health.
Describe the analysis and assessment of clinical document improvement.
Explain information governance as it relates to meaningful use and quality measures.
Demonstrate an understanding of the governmental and accreditation guideline requirements in the management of health records.
Compare and contrast healthcare documentation principles and guidelines for a variety of healthcare settings.
Discuss the many facets of clinical documentation.
Evaluate security measures to protect health information as changes in technology occur.
Assess an EHR system to perform administrative and clerical processes correctly.
Apply critical thinking and decision-making skills in addressing the various issues of electronic health records.

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