Introduces students to the basic concepts of health information management in the healthcare setting. Historical and current record-keeping practices will be explored as well as a basic overview of healthcare delivery systems. The definition of, standards for, and development of both paper and electronic health records as to content, format, evaluation, and completion are discussed. Numbering and filing systems, registries, indexes, forms, and screen design and data exchange are addressed. Other topics include data sets, storage, retrieval, use, and structure of healthcare data; record assembly and analysis; chart location; master patient index; physician documentation and release of information; the role of accrediting and regulatory agencies; facility and staff organization; legal and ethical issues; and the transition to an electronic patient record.
