Effective for May 2022 Examination
- The Examining and Awarding Body is the Institute of Health Records and Information Management and the Examination is open to candidates in the UK and Overseas.
- Only candidates who have been officially accepted by the Institute for Student Membership and who meet all the regulations will be allowed to attempt the Examination. Examination candidates must be fully paid-up members of the Institute.
- Application forms for Student Membership may be obtained from the IHRIM Office. Applicants will normally have had 12 month’s experience of Health Records practice or work in a related field for a period of 12 months.
- The Examination will normally be held on the fourth Monday of May each year.
- The Examination will be held in designated centres throughout the UK and Overseas. Every effort will be made to ensure the candidate attends an Examination Centre close to his/her home.
- The Examination will consist of one paper :
Operational Health Records 2 ½ hour paper
- The pass mark for the paper is 60% but in order to achieve a Distinction the paper must be passed at the first attempt at 80%.
- Candidates applying to take the Examination MUST lodge with the IHRIM Office a completed Examination Registration Form, together with payment for the appropriate amount.
NB: Late registrations will not be accepted and any completed registration forms received without a cheque will be returned
- Any candidate whose registration form is not acknowledged within ten working days of posting should advise the IHRIM Office immediately.
- If a candidate withdraws his/her name before the last day of entry to the Examination the fee will either be returned or carried forward for one year, however an administration charge of £25.00 +VAT will apply. If a candidate fails to attend on the day of the Examination the fee will be carried forward for one year providing a medical certificate is submitted to the Associate Director of Education [Administration] within seven days of the date of the Examination. Otherwise fees are non-returnable unless exceptional circumstances exist and then only at the discretion of the Director of Education. The candidate will be responsible for any increase in fees which may occur between the initial payment and the date the Examination is taken.
- Any amendments to the syllabus will be published 12 months before the Examination date.
- The Examination paper will only be set on the current syllabus bearing the same date as these regulations.
- Any representation that a candidate may wish to make regarding the conduct of the Examination must be made in writing to the Associate Director of Education [Administration], using the Complaints Procedure which is available on the IHRIM Web Site, within seven days of the conclusion of the Examination.
- Candidates can expect to receive their percentage mark. The Newsletter will only show a pass notification.
- Candidates will be notified of the results of the Examination at the end of July of the year in which the Examination was taken. The names of successful candidates will be published in the Newsletter of the Institute.
- The Examination Appeals Procedure is available from the Director of Education of IHRIM.
- Candidates who fail to reach the pass standard in this paper may re-sit the paper on any two  subsequent occasions but within three years of the first attempt on payment of the appropriate fee and according to the syllabus which is in place at the time of the Examination.
- Successful candidates who pass the Examination will be awarded the appropriate Certificate and adopt the title ‘Health Records Practitioner’.
0930 – 0935 Reading Time
0935 – 1205 Written Examination [2 ½ hours]
Operational Health Records: Candidates must answer question 1
and then four others
Five  questions to be answered in total
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
- Methods of physical filing e.g. terminal digit, sequential, alphabetical
- Practical application of retention, archiving and destruction policies (paperbased and electronic) and exceptions
- Storage media e.g. PACS, video, audio, optical disc, scanned images digital options, servers, cloud based
- Understanding of the concept of an Electronic Patient Record (EPR) and local departmental systems and their relationship
- Electronic sharing of patient information
- patient portals
- clinical portals
- sharing between acute and primary care
- population health
- Retrieval and availability of health records including systems for paperbased and electronic records scanned records
- Physical and electronic tracking/tracering systems
- Alternative storage e.g. off site storage, secondary storage, fat folder file, deceased
- Filing storage systems for paperbased records e.g. mobile racking, static racking, carousel, ‘
- Computerised patient management systems eg patient administration systems
- Health Records architecture and clinical document indexing standards
- Knowledge of departmental and standard operating procedures (SOPs)
Data Collection and Use
- Range of demographic details recorded on the Master Patient Index
- Enhanced details collected such as changes in gender and sexual orientation and disabilities
- Data quality e.g. timeliness, accuracy and completeness
- Registration search techniques
- Elimination of double registrations/duplicates
- Use of unique patient identifier [e.g. NHS number, Health and Care Number, Community Index Number]
- Positive Patient Identification
- Clinical Data Capture
- The use of coded clinical data at all stages of the patient journey
- Source of data
- Classifications in current use e.g. ICD, OPCS, SNOMED
- Uses of data eg statistics
- Management and use of patient alerts
- Patient registration
- Management of Clinical documentation internal and external
- Storage of ED documentation, paper based and electronic
- Principles of Child Protection
- Safeguarding vulnerable adults
- Major Incident procedures
- Management of referrals
- Clinic Booking rules
- Procedures for the management of Did not attend [DNA] Was Not Brought (WNB), Unable to attend [UTA]
- Waiting times [Government Initiatives] waiting time guarantees for your home country e.g. 18 week Referral to Treatment Standard, 2 week rule, Cancer Waits etc Stop the Clock
- Clinic Preparation (paperbased, paperlite, electronic and dual processes)
- New and Follow up Appointments, clinic outcomes eg decision to admit or discharge and clinic reconciliation
- Awareness of local and national patient access contracts e.g. eReferral, Patient Focused Booking, Partial Booking
- The admission process including collection of national dataset for your home country
- Methods of admission/transfer and methods of discharge
- Bed management and patient flow
- Management of Health Records for Inpatients and Day Cases eg casenote trolleys
- Booked elective admissions [Management of Waiting Lists and procedures]
- Awareness of waiting times [Government Initiatives] for your home country
Disclosure of Information, Security and Confidentiality
- Data Protection Legislation
- Freedom of Information Act 2000, Freedom of Information (Scotland) Act 2002
- Access to Health Records Act 1990
- Dealing with requests from Solicitors, Insurance Companies, Government Bodies, Police etc
- Consent to release information
- Understanding of principles for confidentiality and security of personal data
- Role Based Access Controls
- Physical Security of paperbased and electronic data e.g. closed libraries, placing of computer screens, logging off
- Understanding of system and information audits
- Authentication of callers [in person and on telephone]
- Understanding the overarching principles of Information Governance/Assurance DPST
- Information Sharing
- Email communication
- Reception [General, Outpatient, Emergency Department, Departmental]
- Communication with patients
- Communication with General Practitioners
- Referral Management Service
- Patients with Special Needs (your home countries Accessible Information Standard)
- Communication with relatives
- Communication with other staff
- Communication with the Public
- Social media
- External bodies eg Police
Health & Safety
- Corporate responsibility
- Personal responsibility
- Moving and handling techniques
- Safety in the workplace
- Risk Assessment
- Incident Reporting and learning
- Role of Health & Safety Officer
Roles and Responsibility
- Ward Clerks
- Medical Secretaries
- Emergency Department Clerical Staff
- Health Records Manager
- Patient Services Staff e.g.
- Library Staff
- Clinic Preparation Staff
- Disclosure Office [Medico Legal Office]
- Admissions Clerk
- Appointments Booking Clerk
- Clinical Coder
- Document Scanning Clerk
- Scanning clerks
- Data Quality clerks