HCA-103: Healthcare Documentation introduces students to the professional standards and practices of medical transcription and editing in today’s healthcare environment. Using a simulation-based approach, students gain practical experience working with patient records from acute care, chronic care, and specialties including cardiology, gastroenterology, neurology, oncology, orthopedics, radiology, and more. Through structured exercises, students will learn to create and edit medical reports that meet compliance, confidentiality, and accuracy standards.

The course also emphasizes the impact of speech recognition technology on documentation practices, equipping students with the ability to identify and correct dictation errors through editing and proofreading. Students will apply guidelines from the Association for Healthcare Documentation Integrity (AHDI) to ensure professional standards in transcription, formatting, and confidentiality.

By working through case studies and clinic simulations, students will build the technical and analytical skills required for producing accurate documentation that supports both clinical care and administrative functions such as billing, auditing, and quality assurance. This course is ideal for students preparing for careers in healthcare administration, health information management, or medical transcription.