Healthcare Documentation

Healthcare Documentation, formerly Medical Transcription, is one of the fastest growing home-based professions in the country. The demand for qualified healthcare documentation specialists continues to accelerate, creating unprecedented financial and career opportunities for people who have the skills to succeed in a fast-paced environment.

 

A healthcare documentation specialist listens to a voice recording or face-to-face information (medical scribe) made by a doctor or other healthcare professional and either transcribes the information into a captured electronic medical record, or reviews and edits a version produced by a voice recognition technology software program for the record. The reports produced become part of the legal medical record, and include medical histories, discharge summaries, physical examination reports, operating room reports, diagnostic imaging studies, consultation reports, autopsy reports, and other documents. These reports are important because they serve as the foundation for ongoing clinical decision-making, continuity of care, maximized reimbursement, and risk management.

 

Richland Community College offers a dynamic Healthcare Documentation certificate that can be completed in three semesters, or a Healthcare Documentation degree that can be completed in four semesters full time, completely online. Richland is proud to offer many medical courses that provide a strong foundation and support for the exceptional healthcare documentation experience attained in our program.

Where does a healthcare documentation specialist work?

 

Many healthcare documentation specialists work from their homes as independent contractors, subcontractors, or as home-based employees. Others work in doctors’ offices, public and private hospitals, teaching hospitals, medical schools, healthcare documentation businesses, clinics, laboratories, pathology and radiology departments, in the Emergency Department of hospitals or physician’s office as a medical scribe, insurance companies, medical libraries, government medical facilities, rehabilitation centers, legal offices, research centers, veterinary medical facilities, nursing homes, etc.

What are other roles available for healthcare documentation specialists?

Qualified healthcare documentation specialists who wish to expand their professional responsibilities may become editors, quality assurance specialists, or supervisors. Experienced healthcare documentation specialists may become teachers, working in schools and colleges to educate future HDSs, work as managers, authors of textbooks, or owners of healthcare documentation businesses. They may provide instruction and training to new EHR users; help create EHR templates; design, test, and implement best practices in EHR use; develop and implement EHR policies and procedures to meet regulatory compliance; offer compliance services and training; provide ongoing training and support to EHR users, and many others.

A career in Healthcare Documentation is right for you if you:

  • See yourself in a career that offers diverse opportunities.
  • Would like to work in health care, but not directly with patients.
  • Have an aptitude for science, but also like management, law, and computers.
  • Want to work from home.
  • Have excellent English grammar skills.
  • Possess good visual and auditory ability with excellent listening skills.
  • Have a high level of concentration for extended periods of time.

Education Options

                               Healthcare Documentation
Required Courses
First Semester Lec Lab Cr RCC Sem/Yr Transfer
HIT 118 Introduction to Healthcare Documentation 2 2 3
HIT 140 Medical Terminology 3 0 3
Subtotals 5 2 6
Second Semester Lec Lab Cr
HIT 141 Anatomy and Physiology Fundamentals 3 0 3
HIT 142 Healthcare Documentation 1 1 6 4
HIT 244 Interpreting Healthcare Records 2 2 3 Spring Only
Subtotals 6 8 10
Third Semester Lec Lab Cr
HIT 225 Speech Recognition Technology Editing 2 2 3 Fall Only
HIT 241 Pharmacology Fundamentals 3 0 3
HIT 242 Healthcare Documentation 2 1 6 4
HIT 248 Pathophysiology 3 0 3
HIT 291 HDS Professional Practice Experience 1 10 3 Any
Subtotals 8 16 13
Fourth Semester Lec Lab Cr
Subtotals 0 0 0
Program Total 32

Program Approval and Association

AhdiRichland Community College’s comprehensive Healthcare Documentation program is approved by the Approval Committee for Certificate Programs (ACCP), a joint committee established by the American Health Information Management Association (AHIMA) and the Association for Healthcare Documentation Integrity (AHDI) to approve Healthcare Documentation education certificate programs. AHIMA and AHDI acknowledge the ACCP approval committee as the process to identify quality Healthcare Documentation education programs that have been evaluated by a peer review process against a minimum set of standards for entry-level Healthcare Documentation professionals. This process allows academic institutions, healthcare organizations, and private companies to be acknowledged as offering an AHDI Approved Healthcare Documentation Programs.

The Registered Healthcare Documentation Specialist (RHDS) exam is an industry-recognized exam. The RHDS credential serves as a benchmark for entry into practice. It demonstrates job-readiness to industry employers. Graduates from approved schools are generally better prepared to sit for the Registered Healthcare Documentation Specialist (RHDS) exam.

 

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