This course covers the fundamentals of health care documentation and medical record production, legal and ethical issues and responsibilities, text expansion software usage, utilization of medical references, and grammar and punctuation in health care-related communication.
- Explain the various reports found in medical records.
- Examine legal issues pertaining to health information and documentation practices.
- Utilize various medical and English references such as dictionaries, medical word books and online pharmaceutical resources.
- Analyze ethical issues pertaining to health information and documentation practices.
- Demonstrate the ability to differentiate content of the seven basic report types.
- Explain the importance of health care documentation.
- Utilize computer technology including software related to productivity in the medical office.
- Display the ability to communicate in written medical language.
- Display professional work habits.
- Demonstrate proper grammar and punctuation in health care-related communication.
- Explain the rationale behind electronic health record implementation.
- Demonstrate methods of entering information in an electronic health record.
- Retrieve information from medical records.