paper
Young: Instructor’s Resource Manual for Kinn’s The Administrative Medical Assistant, 6th Edition
Chapter 14: Medical Records Management
Instructor’s Resource Manual
National Accreditation Competencies and Content
CAAHEP COMPETENCIESAdministrative
3.a.(1)(c). Organize a patient’s medical record
3.a.(1)(d). File medical records
General
3.c.(2)(c). Establish and maintain the medical record
3.c.(2)(d). Document appropriately
ABHES COMPETENCIESCommunication
2.j. Use correct grammar, spelling, and formatting techniques in written works
2.n. Application of electronic technology
2.o. Fundamental writing skills
Administrative Duties
3.b. Prepare and maintain medical records
3.h. File medical records
Legal Concepts
5.a. Determine needs for documentation and reporting
5.b. Document accurately
5.c. Use appropriate guidelines when releasing records or information
5.d Follow established policy in initiating or terminating medical treatment
LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. State several important reasons for keeping accurate medical records.
3. Discuss the ownership of records.
4. Explain the difference between a traditional medical record and a problem-oriented medical record.
5. Illustrate the difference between subjective and objective information.
6. Discuss changing an entry in the patient record and the importance of following correct procedures.
7. List and discuss the basic equipment used in a filing system.
8. Describe the steps in filing a document.
9. List and discuss application of the basic filing systems.
10. Explain how color-coding of files can be useful in a medical facility.
11. Establishy a patient’s medical record.
12. Prepare an informed consent for treatment form.
13. Add supplementary items to an established patient record.
14. Prepare a record release form.
15. Transcribe a machine-dictated letter using a computer or word processor.
16. File medical
Chapter 14: Medical Records Management
Instructor’s Resource Manual
National Accreditation Competencies and Content
CAAHEP COMPETENCIESAdministrative
3.a.(1)(c). Organize a patient’s medical record
3.a.(1)(d). File medical records
General
3.c.(2)(c). Establish and maintain the medical record
3.c.(2)(d). Document appropriately
ABHES COMPETENCIESCommunication
2.j. Use correct grammar, spelling, and formatting techniques in written works
2.n. Application of electronic technology
2.o. Fundamental writing skills
Administrative Duties
3.b. Prepare and maintain medical records
3.h. File medical records
Legal Concepts
5.a. Determine needs for documentation and reporting
5.b. Document accurately
5.c. Use appropriate guidelines when releasing records or information
5.d Follow established policy in initiating or terminating medical treatment
LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. State several important reasons for keeping accurate medical records.
3. Discuss the ownership of records.
4. Explain the difference between a traditional medical record and a problem-oriented medical record.
5. Illustrate the difference between subjective and objective information.
6. Discuss changing an entry in the patient record and the importance of following correct procedures.
7. List and discuss the basic equipment used in a filing system.
8. Describe the steps in filing a document.
9. List and discuss application of the basic filing systems.
10. Explain how color-coding of files can be useful in a medical facility.
11. Establishy a patient’s medical record.
12. Prepare an informed consent for treatment form.
13. Add supplementary items to an established patient record.
14. Prepare a record release form.
15. Transcribe a machine-dictated letter using a computer or word processor.
16. File medical