Electronic Health Record Management

The Electronic Health Record Management Profession

Access to health information is changing the ways doctors care for patients. With the nation’s healthcare system moving to the electronic medical record, numerous employment opportunities exist for medical assistants, health information systems staff, patient registration professionals and other related positions. Healthcare professionals with the ability to understand, update and maintain the electronic health record are in great demand.

The Electronic Health Record Management Program

This Electronic Health Record (EH R) Management program prepares students to understand and use electronic records in a medical practice. Course reviews the implementation and management of electronic health information using common electronic data interchange systems and maintaining the medical, legal, accreditation and regulatory requirements of the electronic health record.

This course covers the following key areas and topics:

• Importance of the medical record as a legal document
• The effect of confidential communication laws on the release of medical information and HIPAA
• Provides a “real life” EH R experience using Medcin software to perform health information tasks
• Shills required to use and EH R to manage patient visit information including the examination, assessment notes and treatment plans.
• Importance of data accuracy, consistency, completeness, and security of information
• Basic code set principles and their applications with an emphasis on the ambulatory/outpatient setting and an introduction to inpatient medical records.

Education and Certification

• Electronic Health Records Management professionals should have or be pursuing a high school diploma or GED.
• Students who complete this comprehensive course would be prepared to sit for the National Healthcareer Association (NHA) Certified Electronic Health Record Specialist (CEHRS) exam.

Detailed Course Topics Covered

• Overview of various healthcare delivery systems with an emphasis on content and documentation requirements of the health record in various healthcare settings
• Designed to provide students with “real life” computer experience using Medcin software and performing tasks in health information departments. Tasks include admission procedures, information retention and retrieval, data entry, chart assembly, data collection, abstracting, code sets, and the release of information
• Structural components of the interactive EH R and how it supports communication and continuity of care including clinical standards such as SNOWMED CT, LOINC, and UMLS
• Perspective on how the EH R impacts work and workflow.
• Importance of the medical record as a legal document and the effect of confidential communication laws on the release of medical information such as protected health information and HIPAA
• The legal procedures involved in court disclosure of medical records
• Tasks include admission procedures, information retention and retrieval, data entry, chart assembly, data collection, code sets, and the release of information