HIM-M 325 Healthcare Information Requirements and Standards I
This course outlines the documents and data content required legally to maintain health records using paper and electronic media. It examines federal, state, and local law; accreditation standards; regulatory requirements for maintaining patient data; and documentation in acute care, psychiatric, and other healthcare settings.
- Verify that documentation in the health record supports the diagnosis and reflects the patient’s progress, clinical findings, and discharge status.
- Compile organization-wide record documentation guidelines.
- Interpret health information standards.
- Manage clinical indices, databases, and registries.
- Appraise current laws and standards related to health information initiatives.
- Identify departmental and organizational survey readiness for accreditation, licensing, and certification processes.
- Comply with ethical standards of practice.
- Differentiate the roles and responsibilities of various providers and disciplines to support documentation requirements throughout the continuum of health care.