Introduction to Health Record Documentation & Coding


Introduction to health information theory supplemented with practical application. Topics include, but are not limited to, the content, uses, and format of the health record; analysis of documentation to ensure that it meets external content directives and desired quality characteristics; the roles and responsibilities of various healthcare professional disciplines in supporting documentation requirements; legal requirements for privacy, confidentiality, and retention of health records; and concepts of data integrity and data governance.

3 Credits: 3 Lecture