SST836 - Health/Medical Records Theory

Outline info
Last revision date 2018-07-20 13:50:05.581
Last review date 2018-07-20 13:50:11.036

Subject Title
Health/Medical Records Theory

Subject Description
Designed to study the record keeping practices in the hospital and physician's office. Emphasis is placed on hospital and medical staff organization, patient record content, procedures in filing, numbering and retention of patient records, qualitative analysis, release of information, forms control and design, indexes and registers, reimbursements, regulatory and accrediting agencies, and alternate health care delivery systems.

Credit Status
This is a credit subject applicable towards the Medical Transcriptionist Specialist Certificate, Medical Unit Clerk and the Medical Administrative Assistant Certificates offered through the Faculty of Continuing Education and Training.

Learning Outcomes
Upon successful completion of this subject the student will be able to:

1. Comprehend various aspects and changes related to workers in the health care field;

2. Contrast and compare the functions of ward/unit clerks, medical transcriptionists, medical secretaries, medical administrative assistants, and employees of a health records department;

3. Recognize the importance of confidentiality of patient records, who may access them and how, e.g., other doctors, lawyers, Court, Police Departments, College of Physicians and Surgeons, insurance companies, Workplace Safety Insurance Board and employers;

4. Understand basic organizational charts within a hospital setting;

5. Understand the limitations imposed by hospital regulations with respect to release of patient information to individuals and companies, i.e. Workplace Safety Insurance Board, lawyers, insurance companies, employers;

6. Understand the Health Record as a document including its content and how quality is achieved, how the chart is completed, its storage and retention;

7. Identify legislation that covers the Health Records Department, such as Regulation 518 in the Public Hospital Act, the Coroner's Act, and the Mental Health Act, including the release of information and consent.

8. Apply knowledge of different cultural requirements with respect to patient's dietary laws, hospital clothing and rituals following a death in the hospital.

9. Understand the nature of statistical reporting that is available in the Health Records Department, how is is used and how it is achieved.

Cheating and Plagiarism
Each student should be aware of the College's policy regarding Cheating and Plagiarism. Seneca's Academic Policy will be strictly enforced.

To support academic honesty at Seneca College, all work submitted by students may be reviewed for authenticity and originality, utilizing software tools and third party services. Please visit the Academic Honesty site on for further information regarding cheating and plagiarism policies and procedures.

All students and employees have the right to study and work in an environment that is free from discrimination and/or harassment. Language or activities that defeat this objective violate the College Policy on Discrimination/Harassment and shall not be tolerated. Information and assistance are available from the Student Conduct Office at

Accommodation for Students with Disabilities
The College will provide reasonable accommodation to students with disabilities in order to promote academic success. If you require accommodation, contact the Counselling and Disabilities Services Office at ext. 22900 to initiate the process for documenting, assessing and implementing your individual accommodation needs.


It is your responsibility to ensure that program requirements and subject prerequisites as outlined are met. Prerequisites are included for your academic protection. Subject content and your professor's teaching assumes that students are academically prepared and instruction will proceed accordingly.  If you lack appropriate prerequisites (or advanced standing for the prerequisite subject) you may be asked to withdraw or transfer to a more appropriate subject, with the risk of academic/financial penalty. It is your responsibility to save documents, articles and notes that the instructor has provided on BlackBoard or in class. Students will not be able to access BlackBoard as of the last day of the student's class.

Topic Outline
The order of the topics is at the discretion of the professor. The content of one module does not have to be completed before another module is started, nor do the modules have to be taught in the order listed. Rather by the end of the subject all the topics will have been covered.

  • Guest speakers 
  • Changes in the health care field
  • Various responsibilities of different medical administrative office personnel
  • Patient records
  • Organizational charts
  • Legislation
  • Impact of multiculturalism on health care
  • Major project to be completed

Mode of Instruction
Students learn through classroom lectures as well as homework assignments.

Blended Models of delivery may also be available. 

Prescribed Texts
Online: Essentials of Health Information Management. Michelle A Green, Mary Jo Mowie. Delmar Learning 3rd Edition, ISBN# 1285177266

Reference Material

Required Supplies

Promotion Policy

Grading Policy
A+ 90%  to  100%
A 80%  to  89%
B+ 75%  to  79%
B 70%  to  74%
C+ 65%  to  69%
C 60%  to  64%
D+ 55%  to  59%
D 50%  to  54%
F 0%    to  49% (Not a Pass)
EXC Excellent
SAT Satisfactory
UNSAT Unsatisfactory

For further information, see a copy of the Academic Policy, available online ( or at Seneca's Registrar's Offices.

Modes of Evaluation
Since this is a professional credit subject, marking standards reinforce professional practice by demanding legible, tidy work. Written materials should be well organized, correctly formatted and grammatically correct, with proper spelling and punctuation.

Please Note

  • Assignments, tests and the final examination are evaluated on subject knowledge as well as correct language usage, organization, and mastery of the subject. 
  • In recognition of the significance of proper language skills in the workplace, marks are deducted, in accordance with departmental policy, for language errors on all tests, assignments and exams. (i.e. spelling, grammar, word usage, sentence, and paragraph structure, etc.) 

  • The student must retain a copy of all assignments.
  • If assignments are handed in late without sufficient medical or other reason, which must be documented and approved, two marks per day will be deducted for each day the assignment is late up to a maximum of 10 marks in total. 
  • Assignments will not be accepted after the return of graded assignments to the class and/or the provision to the class of the answers to the assignment.
  • Written assignments must be word processed. At the professor’s discretion, assignments that are not word processed, may be subject to mark deduction or not accepted. 
  • For particulars, please obtain standards, dates, etc. from your instructor.

Absenteeism and Tests
  • Students should be aware that absenteeism will impact on their ability to achieve satisfactory grades.
  • If you miss a test, you must provide the reason in writing to the instructor within one week. If your reason is accepted, the weighting of that test will be added to that of the final exam. Otherwise, you will be given a zero for the test. You must submit an original doctor’s certificate identifying the date, length of time of expected absence and the specific reason for your absence, or other appropriate documentation.
  • Progress tests and quizzes may not be announced in advance and details of the assignment requirements may be explained in class.

Final Exam/ Final Assignment
  • Students must attain a grade of at least 50% to pass the course.
Field Placement Requirements

Students who do not successfully complete all professional subjects may not be eligible for placement. 

Academic Honesty

Students at Seneca College are expected to be honest and forthright in their academic endeavours. When students cheat on an examination, steal the words or ideas of another, or falsify their research results, it corrupts the learning process. A Seneca College degree, diploma or certificate signifies to society mastery of a set of defined learning outcomes in a designated field of study. If academic credit is obtained dishonestly, the value of every graduate's diploma in the field of study is diminished, as is the reputation of the college as a whole.

Penalties for Academic Dishonesty

The penalty for a first offence is a grade of '0' on the assignment or examination. The penalty for the second offence is expulsion for a time period determined by the Academic Honesty Committee, normally for a minimum of three semesters. For further information refer to the policies section of the Seneca College student handbook, or to the following website:

Grading is based on the following marking scheme:

3 assignments (25% each) 75%
Final Exam 25%

Materials permitted into tests and exams are at the discretion of the instructor.

3 Assignments 25% each  
Final Exam 25%

Approved by: Sandra Noble