Covers medical documentation standards, electronic health records, and privacy rules in clinical settings.
About this course
Health records management focuses on the principles and practices required to maintain accurate and secure patient information. You will learn how medical documentation standards apply in clinical settings, with an emphasis on electronic health records (EHR) and privacy legislation. The course covers the full lifecycle of a health record, from creation and authentication to retrieval, retention, and secure disposal.
You will explore the legal and ethical frameworks that govern health information in Ontario, including privacy law and professional standards. Practical exercises allow you to practice correct documentation techniques and apply standardized coding systems to real-world scenarios. By the end of the term, you will be able to manage patient information securely and efficiently in both paper-based and digital environments.
Who takes this course
Credits: 3 · Hours: 45
Prerequisites
None
Learning outcomes
- Explain the legal and ethical requirements for maintaining health records under provincial privacy legislation.
- Demonstrate correct documentation practices for electronic health records (EHR) and paper-based files.
- Apply standardized coding systems and terminology to clinical documentation.
- Manage the retrieval, retention, and secure disposal of patient records in compliance with policy.
Evaluation
| Component | Weight (%) |
| Mid-term examination | 30 |
| Practical documentation scenarios | 40 |
| Final examination | 30 |