Certificate Examination Syllabus and Regulations [UK] - Syllabus


Where relevant answer the questions as they apply to your Home Country

Certificate of the Institute

The Certificate Examination is the next step in the qualification structure and is designed to assist Health Records Staff, Health Informatics and Information Staff to improve their overall knowledge of functions and services and gain a professional qualification.

The modules are as follows:-

Health Records Management

i. Candidates must be able to demonstrate a knowledge of the following pieces of legislation:

· Access to Health Records Act 1990 – application of the Act

· Data Protection Act 1998 – the principles of Data Protection and arrangements for Subject Access Requests

· Freedom of Information Act 2000/Freedom of Information (Scotland) Act 2002 – the principles

· Caldicott Reports

· NHS Code of Practice Records Management or Retention Schedules as they apply in your own Home Country

· Clinical Standards of record keeping

· Current reports relating to healthcare and e-Health strategy which are relevant to Personal Health Records practice in your Home Country

· Information Governance/Assurance Standards as they apply

ii. Release of information as a statutory requirement e.g. births and deaths

iii. Dealing with requests for information from outside bodies e.g. solicitors, police, coroners, insurance companies

iv. Physical security issues [closed libraries, logging off PCs, placing of computer screens]

v. Integrated Care records - GP records, Community, Social Care Records, Mental Health Recods

vi. The organisation of Health Records Services

vii. The role of Health Records Committees

viii. Monitoring of Performance Standards for Personal Health Records

ix. Critical success factors for effective patient waiting time management

x. Systems review and improvement


Information Management

i. Sources of Clinical Coding Data

ii. The uses of Clinical Coded Data

iii. Data Quality and accuracy – auditing, rectification of errors, validation, unique number uptake

iv. Classifications currently in use

v. The purpose of Cancer Registries

vi. Application and uses of epidemiological information

vii. Knowledge of NHS Data Standards and Definitions as they apply in your own Home Country

viii. Awareness of common hospital statistics

ix. The alternative methods of presenting data

x. Form design for effective data capture

xi. A sound knowledge of the role of information in supporting clinical processes

Human Resources

i. The recruitment and selection process

ii. Deployment of staff to meet the departmental objectives, teambuilding, managing workloads, problem solving

iii. Staff appraisal and performance review including training needs analysis

iv. Training and development process

v. Dealing with poor performance

vi. Relevant Personnel policies (grievance, disciplinary, absence management, performance management/capability, dignity at work, health and safety, equality and diversity, disability)

vii. Communication (verbal, written, use of templates with written correspondence, electronic communication)

viii. Dealing with Violence and Aggression

ix. Concept of Service efficiency, improvement and transformation

IT Application & Development [Practical]

i. The range of IT systems in use in the NHS e.g. Patient Administration Systems (PAS), Patient Management Systems (PMS), Departmental Systems, Clinical Systems, Audit Systems, Order Communications and Results Reporting Systems (OCS), Decision Support Systems, Picture Archiving Communication Systems (PACS)

ii. Development of Electronic Patient Records [EPR] and Electronic Health Records [EHR] in your Home Country

iii. Development of Clinical and Patient Portals in your Home Country

iv. Hardware Definitions e.g. personal computer, mainframe computer, monitor, printer, modem, keyboard, mouse, hard drive, floppy disk, Rapid Access Memory [RAM], Read Only Memory [ROM], Central Processing Unit [CPU], Surge Protector, UPS, Ports, Scanner, digital camera, WORM technology, NHS net, LAN, WAN

v. Software definitions e.g. installation, word processors, spreadsheets, databases, desktop publishing, application suite, utility software, games software, programmes, system analysis

vi. File and management structure on a PC

vii. Secure transportation of personal health data

viii. Use of the internet and intranet

ix. Data input methods

x. Data Integrity

xi. Backups and recovery strategies


Medical Terminology

i. Demonstrate an understanding of the component parts of medical terms and be able to give meaning to these by constructing or explaining medical terms: knowledge of roots, suffixes, prefixes and combining vowels, plurals of terms

ii. Have a basic understanding of the meaning and purpose of pathological and radiological tests and other diagnostic tests, procedures e.g. bronchoscopy, endoscopy, MRI Scan, Heaf Test, ESR

Information Governance/Assurance

i. What is Information Governance/Assurance?

ii. Awareness of personal responsibility for Information Governance/Assurance

iii. Awareness of HORUS principles (Holding, Obtaining, Recording and Using Information)

iv. Sharing Information across Organisations (principles of Caldicott 2)

v. The Information Governance/Assurance Framework and its impact on Health Records Services

vi. Legal aspects of confidentiality

vii. Application of Information Governance/Assurance Framework across the NHS

viii. Information Governance/Assurance Standards as they apply in your Home Country

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