hcis255 | undergraduate

Structure And Design Of Electronic Health Records

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This course introduces the fundamentals of computer systems and the role of information processing in today's health care environment. An overview is presented of information systems, systems development, operating systems and programming, database management, networking and telecommunications, the Internet, and how these resources are applied in the health care industry.

This undergraduate-level course is 9 This course is available as part of a degree or certificate program. To enroll, speak with an Enrollment Representative.

Course details:

Credits: 3
Continuing education units: XX
Professional development units: XX
Duration: 9

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    Link Between the Revenue Cycle and the Clinical Record

    • Describe the electronic tools used to ensure accurate evaluation and management coding.
    • Describe the importance of an accurate registration.
    • Identify minimum documentation requirements needed for reimbursement.
    • Describe diagnosis codes.

    Health Information Exchanges and Leveraging the Internet

    • Describe the relationship between health information exchange (HIE) and health reform.
    • Identify privacy concerns with the use of HIE and the Internet.
    • Identify consumer options within the health care Internet market.

    Regulatory Compliance, Privacy, and Security

    • Identify physical and technical safeguards used to secure protected health information (PHI).
    • Explain the application of electronic signatures.
    • Identify key components of a compliance plan.

    How the EHR Can Improve Patient Health

    • Explain how improved communication affects patient health.
    • Describe prevention and early detection strategies.


    • Identify documentation requirements for a history and physical.
    • Demonstrate the ability to locate and enter health data into the EHR.
    • Document patient clinical results with an anatomical drawing.

    Defining the Health Record

    • Explain the importance of the health record.
    • Identify key components of the health record.
    • Identify structured coding systems.

    The Flow of Information Into the Health Record

    • Describe the process for capturing and recording electronic health record (EHR) data.
    • Define structured data sets.
    • Identify the benefits and challenges of structured data sets.

    Computerized Provider Order Entry

    • Define computerized physician order entry (CPOE).
    • Identify benefits of physician order entry.
    • Explain how CPOE can protect the patient and the provider from medical errors.

    Importance of Trending and Clinical Decision Support Tools

    • Describe the purpose and utility of the clinical flow sheet.
    • Explain the importance of the problem list.
    • Identify clinical decision support tools.

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