11 May WHAT ARE THE TYPES OF RE CORDS COMMON TO A HEALTHCARE SETTING?
In class, you have practiced medical records management skills by organizing and analyzing sample medical records, both hard-copy and through EMR ( Spring charts). Based on this practice and the information you learned from classroom discussions, assigned readings, and research; d escribe the following: 1. Identify and describe the content required to be maintained in a medical record. What are the types of re cords common to a healthcare setting? Describe standard chart configuration.VC. 6, VC. 12 2. Compare and contrast the pros and cons of the two major systems for organizing medical records, source -oriented and problem -oriented records. VC. 5 3. Describe each element of the “S.O.A.P.” method of documentation, and give an example of each. 4. Describe the standard protocols used for filing medical records. Include in your discussion, an explanation of each indexing rule, as discussed in class. This should include electronic, alphabetic, numeric and subject orientation . VC. 9, VC. 10 5. Identify and define all equipment needed to complete accurate and timely medical record management. VC. 8 6. Compare and contrast the pros and cons of EMR. Include in your discussion the requirements for maintaining medical record safety/security, patient information, scheduling and accounting. VC. 7, VC. 11
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