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Health Information

Knowledge of types of health information and rules and regulations surrounding their use.

Critical Work Functions

  • Understand the role and importance of health information
    • Identify and understand health documentation requirements
      • Identify and understand health insurance documentation requirements
        • Maintain the security and confidentiality of patient records, per HIPAA & other related regulations
          • Understand the two-way flow of information and data through the medical organization (originating with both patient and provider)
            • Ensure documentation in health records reflect completeness, accuracy, timeliness, appropriateness, quality, integrity, and authenticity as required
              • Use medical terminology within a scope of practice in order to interpret, transcribe and communicate information, data and observations
                • Use appropriate procedures for submitting and accessing medical information through a Health Information Exchange
                  • Transmit documents (via internet or fax) in a secure manner
                    • Dispose of patient information and records appropriately
                      Technical Content Areas

                      • The Medical Health Record (paper, electronic, hybrid)
                        • History - What care has been provided and what is outstanding
                        • SOAP (Subjective, Objective, Assessment, Plan)
                          • Outcomes of care provided and responses to the plan of care
                          • Current patient status & assessments
                          • Support decisions based on assessments to drive new plans of care
                        • Diagnoses
                        • Treatments, Procedures
                        • Progress notes
                        • Laboratory results
                        • Consents
                        • Nursing and other therapeutic monitoring reports
                        • Administrative and referral documentation
                        • Discharge summary and instructions
                      • Health Information Exchange
                        • Software
                        • Access, retrieval, and submission procedures
                      • Medical terminology foundations
                        • Diagnostic and procedure terms
                        • Roots, prefixes, suffixes, eponyms
                        • Abbreviations
                        • Acronyms
                      • Record keeping and documentation procedures
                        • Confidentiality
                        • Release of information documentation