Medical Records Course Descriptions and Training Information
Health information technicians need to know how to create, store, code and classify medical records. Medical records courses are usually completed within a full certificate or degree program.
Health information technology programs and medical office training programs offer medical records courses. These educational programs often culminate in a certificate or associate degree and cover not only medical records coding but also include coursework that familiarizes students with medical office procedures, accounting, customer service, productivity software and pharmacology. There are also specialized certificate programs in medical records coding.
Some common medical records courses included in such programs include those in medical terminology, records coding and classification, insurance and billing procedures, medical records fundamentals and information technology. Students learn the basics of medical records creation and management, including the laws applying to privacy, as well as master the terminology used in the medical field. They usually also learn to use medical information management software and to code and classify records for billing and insurance reimbursement.
Many of these certificate and associate's degree programs require a practicum, internship or externship. Depending on the program completed, graduates may be able to pursue an industry certification, such as the Certified Medical Administrative Assistant (CMAA) or the numerous coding and health information technology certifications that the American Academy of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA) offer.
List of Medical Records Courses
Certificate and associate's programs may include some of the medical records courses described below.
Medical Records Fundamentals
In this class, students learn how to properly create and store medical files. This serves as a foundation for subsequent coursework in a medical records certificate or degree. Paper and electronic records are discussed. Students also explore principles of information management like records retention and disposition.
This course is usually taken early in a medical records program and includes learning professional standards in filing, doctor-patient confidentiality and ethical behavior. State and federal laws related to the collection, retention and sharing of patient data are analyzed.
It's essential that medical records professionals understand the anatomical, physiological and pathological terms used in patient files and related records. Coursework helps students to master proper spelling and pronunciation. This is usually a required class taken early in a medical records program.
This typically required class introduces students to common technologies used in the workplace. In addition to lectures, hands-on learning opportunities allow students to practice creating, updating, storing and accessing medical records like patient charts, appointment schedules and test results.
Coding and Classification of Records
The practical application of coding and classification for billing and insurance reimbursement is the focus of this course. Lessons cover codes and classifications for medical procedures and medical diagnoses and guidelines for use in medical records. Students also learn HIPAA (Health Insurance Portability and Accountability Act) guidelines and how they relate to the preparation of medical records.
Insurance and Billing Procedures
Students in this required class are introduced to common health insurance company requirements for handling claims and typical office billing procedures. Students practice processing Medicare, Medicaid and workers compensation claims for outpatient and in patient treatment. Most classes also include lessons on legal and ethical aspects of working with medical records within the context of insurance and billing processes.
Students can enroll in medical records training courses as part of certificate programs, which usually take about a year or less, or more comprehensive associate degree programs, which are usually 2-year programs. The decision to study full or part time can also influence how long students study before beginning careers as medical office assistants, office managers or medical records clerks. In some programs, students are required to complete a practicum prior to graduation.
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