IHRIM

Foundation Examination Syllabus and Regulations [UK and Overseas] - Syllabus

Syllabus

Where relevant answer the questions as they apply to your home country.

Operational Health Records

Candidates should be able to describe and explain the methods of health records procedures for patient management from initial referral to discharge including:

Health Records Management

  1. Methods of filing e.g. terminal digit, sequential, alphabetical
  2. Practical application of retention, archiving and destruction policies (paper based and electronic)
  3. Storage media e.g. PACS, video, audio, optical disc, scanned images
  4. Understanding of the concept of Electronic Personal Health Records (EPHR)
  5. Understanding of the concept of Clinical and Patient Portals
  6. Retrieval and availability of case notes including systems for paper based and electronic records
  7. Case note tracking/tracering systems
  8. Alternative storage e.g. off site storage, secondary storage, fat folder file, digital
  9. Filing storage system for paper based records e.g. mobile racking, static racking, carousel, 'Lectrievers'
  10. Computerised patient management systems
  11. Personal Health Records architecture and clinical document indexing standards

Data Collection and Use

  1. Range of demographic details recorded on the Master Patient Index
  2. Data quality e.g. timeliness, accuracy and completeness
  3. Registration search techniques
  4. Elimination of double registrations
  5. Use of unique patient identifier [e.g. NHS number, Health and Care Number, Community Index Number]
  6. Positive Patient Identification
  7. Clinical Data Capture
    1. The use of coded clinical data at all stages of the patient journey
    2. Organisation of the department
    3. Source of data
    4. Classifications in current use e.g. ICD, OPCS, SNOMED

Emergency Department

  1. Patient registration
  2. Management of Clinical documentation
  3. Storage of ED documentation, paper based and electronic
  4. Principles of Child Protection
  5. Safeguarding vulnerable adults
  6. Major Incident procedures

Outpatients

  1. Clinic Booking rules
  2. Procedures for the management of Did not attend [DNA], Unable to attend [UTA]
  3. Waiting times [Government Initiatives] waiting time guarantees for your home country e.g. 18 week Referral to Treatment Standard, Cancer Waits etc
  4. Clinic Preparation (paper based, paperlite and electronic)
  5. New and Follow up Appointments, clinic outcomes and clinic reconciliation
  6. Discharge from Outpatient Care
  7. Awareness of local and national patient access contracts e.g. eReferral, Patient Focused Booking, Partial Booking

Inpatients

  1. The admission process involving collection of national dataset for your home country
  2. Methods of admission/transfer and discharge
  3. Bed management
  4. Management of Personal Health Records for Inpatients and Day Cases
  5. Booked elective admissions [Management of Waiting Lists and procedures]
  6. Awareness of waiting times [Government Initiatives] for your home country

Disclosure of Information, Security and Confidentiality

  1. Data Protection Act 1998
  2. Freedom of Information Act 2000, Freedom of Information (Scotland) Act 2002
  3. Access to Health Records Act 1990
  4. Dealing with requests from Solicitors, Insurance Companies, Government Bodies, Police etc
  5. Consent to release information
  6. Understanding of principles for confidentiality and security of personal data
  7. Role Based Access Controls
  8. Physical Security of paper based and electronic data e.g. closed libraries, placing of computer screens, logging off
  9. Understanding of system and information audits
  10. Safe haven fax procedures
  11. Authentication of callers [in person and on telephone]
  12. Caldicott
  13. Understanding the overarching principles of Information Governance/Assurance

Communication

  1. Reception [General, Outpatient, Emergency Department, Departmental]
  2. Communication with patients
  3. Communication with General Practitioners
  4. Referral Management Service
  5. Patients with Special Needs (your home countries Accessible Information Standard)
  6. Communications with relatives
  7. Communication with other staff
  8. Communication with the Public

Health & Safety

  1. Corporate responsibility
  2. Personal responsibility
  3. Moving and handling techniques
  4. Safety in the workplace
  5. Risk Assessment
  6. Incident Reporting
  7. Role of Health & Safety Officer

Roles and Responsibility

  1. Ward Clerks
  2. Medical Secretaries
  3. Emergency Department Clerical Staff
  4. Health Records Manager
  5. Other Health Records Staff e.g.
    1. Library Staff
    2. Clinic Preparation Staff
    3. Disclosure Office [Medico Legal Office]
    4. Admissions Clerk
    5. Appointments Booking Clerk
    6. Receptionist
    7. Clinical Coder
    8. Document Scanning Clerk

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