Medical Records Tech Syllabus

TIME FOR COMPLETION
220 hours (180 instruction, 40 laboratory/practicum)

Chapter 1 – Medical Record Technician

Chapter 2 – Medical Records
A. Rationale and Application
B. Record Number and Forms
C. Medical Reports

  1. History and Physical
  2. Clinical and Laboratory
  3. Autopsy
  4. Operation

Chapter 3 – Departmental Responsibilities
A. The Department
B. Step by Step Process
C. Filing Systems

  1. Straight Numeric Filing
  2. Terminal Digital Filing

D. Data and Statistics

Chapter 4 – Electronic Medical Records
A. EMR
B. Differences in EMR/EHR
C. Benefits of EHR
D. Paper Medical Records
E. Computerization of Medical Records

Chapter 5 – Policies and Procedures
A. Policies and Procedures
B. Confidential Information Management
C. Public Law – HIPAA

Chapter 6 – Workplace Assets

Chapter 7 – Medical Professionals

Chapter 9 – Coding
A. Disease Classifications and Coding
B. ICD9-10 Codes
C. CPT Codes
D. HCPCS
E. APC Codes
F. Coding Software
G. Coding Practice

Appendix