Healthcare Documentation Specialist Certification Outline

Overview

This program is designed to explain the importance of clinical standards in the development of interoperable electronic health records. It’s fast-paced, engaging, and overflowing with relevant information that will help hopeful professionals kickstart or advance their careers. Learners will explore best practices for several procedures, including (but not limited to) coding and reimbursement. They’ll also get extensive training in medical terminology, anatomy, physiology, medico-legal rules, and HIPAA.

Program Timeline

The best part about our Certified Healthcare Documentation Specialist program is that you can move through all the content as fast as you retain information.

11 individual courses

12 months of full program access

Study Format

Training for a new career might seem like a massive undertaking. Not with our platform—our online Certified Healthcare Documentation Specialist program is there whenever and wherever you’re ready.

Learn from home (or anywhere)

Study online (anytime)

Support

We’ll have your back from day one all the way through course completion. Reach out to us any time with questions, and our incredible Career Advisors will take good care of you.

One-on-one support

Phone, live chat, and email

Certified Healthcare Documentation Specialist Program Courses

Our program outline is divided into 11 bite-sized courses that cover everything from the basics of coding to the importance of HIPAA compliance.

Program Orientation: Certified Healthcare Documentation Specialist

Prepare to initiate the Certified Healthcare Documentation Specialist Program.

Law, Liability, and Ethics for Healthcare

Describe the structure of the healthcare industry and how it relates to the medical office profession.
Identify law and regulations related to the health care workplace.
Describe how law flows from the constitution to the courtroom.
Identify criminal acts and intentional torts.
Recognize what makes a contract and who can contract.
Identify medical malpractice and other lawsuits.
Explain the characteristics, ownership, and confidentiality of the health record.
Recognize the importance of the laws and ethics of patient confidentiality.
Explain professional ethics and how they apply to patients.
Recognize ethical issues surrounding the beginning of life.
Recognize ethical issues surrounding death and dying.

Comprehensive HIPAA

Describe HIPAA basics.
Understand the HIPAA Privacy Rule.
Understand the HIPAA Security Rule.
Describe the HITECH Act.
Explain regulations for business associates.
Summarize HIPAA documentation and training.
Review applied HIPAA security for healthcare professionals.

Release of Information

Explain the release of information process.
Delineate patient’s rights.
Navigate the U.S. Department of Health and Human Services website.
Recall answers to frequently asked questions an ROI professional might encounter.
List breach notification requirements.
Outline basic characteristics of HIPAA enforcement cases.

Comprehensive Medical Terminology

Analyze how medical terms are built using common word parts
Properly spell, define, and pronounce medical terms associated with each of the major body systems
Identify and define the word parts most frequently associated with the major body systems
Interpret common abbreviations used in medical terminology and cautions to remember when using them

Anatomy and Physiology

Identify the structures, locations, and functions of major body systems and the organs that comprise them.
Explain how the organs of the major body systems interact and maintain homeostasis.
Compare various risk factors leading to high mortality and morbidity.
Describe the components of cell structure and their functions.
Summarize how infectious agents affect cellular growth and function.
Define basic anatomical terms.

Comprehensive Pharmacology

Define basic pharmacology terminology.
Identify U.S. drug laws and explain their importance in patient care and health services documentation.
Differentiate among drug classifications, routes of entry, mechanisms of action, and therapeutic treatments related to specific body systems and disease conditions..
Identify medication side effects, precautions, contraindications, and interactions.
Identify major drug standards, legislation, legal responsibilities of the health care practitioner when dispensing medications.
Identify the major drug classification systems and differentiate among the various types of drug names with examples.
Evaluate the standard and online pharmacological references in use today.
Classify the sources of drugs, examine their pharmacokinetic processes, and analyze the variables that affect drug actions and effects.
Analyze various drug forms, routes of delivery, and the supplies and techniques necessary for safe and appropriate administration.
Identify commonly used medications and their characteristics.
Identify the sources, mechanism of action, and indications for specific drug therapies.
Analyze the side effects, precautions, contraindications, and interactions for specific medications.
Assess the factors that influence the absorption and effectiveness of drugs.
Analyze the physiological effects of prolonged drug use and discuss the responsibilities of a health care practitioner in addressing and treating drug abuse.
Investigate recent actions taken by the government and by manufacturers for specific drugs.
Identify the key factors involved in considering drug therapies for older adults.

Comprehensive Electronic Health Records

Demonstrate how patient records are used and regulated.
Complete tasks required for scheduling patient appointments
Clinical information reporting.
Apply basic coding for reimbursement claims.
Revenue cycle and financial reporting.

Scribe Essentials

Understand the history of the Medical Scribe industry.
Understand what a medical scribe is.
Understand the importance of HIPAA as a medical scribe.
Underline the medical scribe’s scope of care and ability to maintain integrity and patient privacy.
Describe the primary roles and responsibilities as a medical scribe.
Understand the necessary skills of a medical scribe.
Review do-nots and tips to succeed as a medical scribe.
Relate to different clinical environments as a member of a multidisciplinary team.
Understand the different clinical settings.
Know the difference between outpatient facilities/clinics and the emergency department workflow.
Apply medical terminology when documenting and communicating among healthcare professionals.
Review the vital signs.
Record basic medical abbreviations.
Illustrate knowledge of common prefixes and suffixes used in medical terminology.
Distinguish the difference between subjective and objective findings.
Conduct through documentation of the chief complaint, history of present illness, review of systems, current medication regimen, allergies, medical history and family history.
Have a baseline understanding of different physical exam findings.
Understand what information will be added to the assessment and plan.
Execute the standard order of documentation by using the acronym SOAP.
Know the common laboratory tests and what they are used to test for in regard to medical decision making.
Know the common medical imaging and what they are used for in regard to medical decision making.
Understand vital signs and physical exam findings and how they contribute to medical decision making.
Identify and document the final diagnosis from the provider.
Summarize the patient’s disposition, plan and discharge instructions as ordered from the provider.
Demonstrate active listening skills to document the patient visit.
Navigate the EHR Go platform and successfully enter the visit information into the EHR system provided.
Utilize what you have learned in previous courses in this program to practice a “real life” scribing exercise to include medical terminology and pharmacology.

Career Success in Healthcare

Define “professionalism” and “success” in your own terms.
Differentiate between long-, medium-, and short-range goals.
Assess and develop your time management skills.
Develop plans to enhance your creative and critical thinking.
Use an effective decision-making process to maximize your chances for success.
Describe methods to maximize verbal, nonverbal, and written communication.
Describe the healthcare system.
Describe and discuss organizational structure, communication channels, and lines of authority.
Develop an understanding of the factors that affect group dynamics and use these skills to maximize your leadership potential.
Explain ethics and how they relate to health care professionals.
Define continuing education, certification, and licensure.

Program Completion: Certified Healthcare Documentation Specialist

Prepare to take next steps for program completion.