Overview

1. Foundations of Health Information ManagementHistory and evolution of medical recordsRoles in HIM: Technician, Officer, Auditor2. Types and Formats of Medical RecordsInpatient, Outpatient, Emergency recordsOPD/IPD register maintenancePaper vs Electronic records3. Medical Terminology for Record-KeepingBody systems, diagnostic proceduresAbbreviations and acronyms used in records4. Hospital Departments and MRD WorkflowAdmission, discharge, and transfer recordsCoordination with nursing, billing, diagnostic, and pharmacy units5. Coding and Classification SystemsOverview of ICD-10, CPT, SNOMEDAssigning codes to diseases, treatments, and procedures6. Legal, Ethical, and Regulatory ComplianceRTI, HIPAA (for international exposure), Indian lawsMedical record requirements for medico-legal casesConsent, confidentiality, and disclosure policy7. Medical Records Department (MRD) OperationsMRD design, staffing, policiesIndexing and numbering systems (unit, serial, serial-unit)8. Digital Health and Electronic Health Records (EHR)EHR/EMR software overviewBenefits and limitationsNABH & NDHM compliance in digital records9. Retention, Archiving & Record DisposalRecord retention policies (as per MOHFW/NABH)Disposal of expired records - legal process10. Disaster Preparedness and Risk ManagementFire, flood, and cyber-security threatsRecord recovery and contingency plans11. Data Quality & Clinical Documentation Improvement (CDI)Role in audits and data accuracy checksAvoiding documentation errors12. MRM in Insurance and Claims ProcessingRole of MRD in medical billingTPA documentation support and pre-auth form handling13. Healthcare Analytics Basics (Optional/Advanced)Use of records in quality indicators, trends, and researchDashboards, KPIs, and patient statistics14. Communication, Ethics & ProfessionalismHandling difficult situationsEthical dilemmas and patient interactions15. Project Work / Internship / Hospital VisitLive exposure to hospital MRDCase study on record lifecycle

Skills

Reviews