Medical Records (Advanced)

Recipients of the Medical Records credential have demonstrated concept proficiency and completed  the following tasks:

Activity 1 – Setting Up The Medical Forms
(a) Copied Insurance Form to flash drive and renamed.
(b) Copied remaining 8 forms to flash drive and renamed.
(c) Created new folder for Activity 4, copied 4 files into it and renamed files.
(d) Created new folder for Activity 5, copied 5 files into it and renamed files.
(e) Practiced using 2 electronic forms but did not save work.
(f) Sorted 4 sets of lab sheets by patient’s name.
(g) Showed work to instructor.
(h) Put away materials.

Activity 2 – Medical Terminology
(a) Studied List of Word Elements.
(b) Opened file “Word Root Worksheet” and completed worksheet. Renamed file and saved work.
(c) Opened file “Medical Terminology Worksheet” and completed worksheet. Renamed file and saved work.
(d) Compared answers with classmate and discussed differences.
(e) Showed work to instructor.
(f) Used Answer Keys to evaluate worksheets with classmate.
(g) Put materials away.

Activity 3 – Medical Transcription
(a) Opened file “Transcription Worksheet” and renamed.
(b) Entered name and date.
(c) Listened to audio of “Sentences from Case Histories” following along with printed student instructions.
(d) Listened to audio again and transcribed copy (looking at sentences).
(e) Saved work and doublechecked against printed copy.
(f) Listened to audio a third time transcribing without looking at printed copy.
(g) Followed same procedure to transcribe “Patient History and Physical Examination” both with and without using copy.
(h) Showed work to instructor.
(i) Put materials away.

Activity 4 – Electronic Records
(a) Opened file “Medical History Form”.
(b) Asked patient to have a seat and collected his or her driver’s license and insurance card.
(c) Found information on driver’s license and recorded on form accurately.
(d) Found information on insurance card and recorded on form accurately.
(e) Gathered marital status, occupation and referral information from patient and recorded on form accurately.
(f) Recorded present illness/complaints on form accurately.
(g) Recorded past illnesses/conditions on form accurately. Saved work.
(h) Opened “Nurse’s Notes Form” and “Clinical Laboratory Results Form” and completed information at top of form. Saved work.
(i) Opened “Census Report Form” and completed accurately. Saved work.
(j) Showed work to instructor.
(k) Put materials away.

Activity 5 – Electronic Patient Chart Maintenance
(a) Read Medical History Booklet and chose patient for this activity.
(b) Opened folder “Act. 5 Patient Maintenance Chart” and double-checked for contents of 5 needed forms.
(c) Completed top of each form for selected patient.
(d) Opened “Medical History Form” file and accurately completed remaining information for selected patient from the Medical History Booklet.
(e) Completed green box at top right of Medical History Form with pertinent insurance information.
(f) Double-checked work and saved work.
(g) Showed work to instructor.
(h) Separated four sets of lab sheets by patient.
(i) Opened the “Clinical Lab Results Form” and used the lab sheets to complete the form. Saved work.
(j) Sorted Team Assignment Sheets by date.
(k) Opened “Nurse’s Notes Form” and accurately transferred information from the Team Assignment Sheets to the Nurse’s Notes Form.
(l) Put Diet Sheets in order by date.
(m) Accurately recorded information from Diet Sheet about selected patient onto Nurse’s Notes Form. Saved work.
(n) Opened “Insurance Form” file. Used Medical History Booklet to accurately complete the Insurance Form for selected patient. Saved work.
(o) Showed work to instructor.
(p) Opened “Coding Form” file. Accurately completed form using Insurance Form for selected patient. Saved work.
(q) Showed work to instructor.
(r) Put materials away.

For more information on digital badge credentialing, check out the Education Associates’ Quick-Start Guide.

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