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Title

Medical Charting and Documentation, Part 1: Medical Record Uses, Content, and Formats (1 credit hours)

Abstract

This module discusses health information use for patient care management and describes medical record content areas. The module concludes by describing the typical contents and organization of the three most commonly used record formats: Source-oriented, problem-oriented, and integrated formats.

Planners, content specialists and feedback personnel have declared that there is no conflict of interest in the preparation and content of this module. There is no commercial support for or endorsement of products in this module.

Author

Katherine Ott, MSW, ELS

Katherine Ott, M.S.W., ELS, is a managing editor for the American Society of Radiologic Technologists and a certified Editor in the Life Sciences. She has written and edited several articles on medical imaging and radiation therapy for various ASRT publications.

Barbara Wallace, RHIA, CCS, CCS-P

Contributing Author
Barbara Wallace is an associate professor of Health Information Management at Sinclair Community College (Dayton, OH). She has over 12 years experience as an HIM educator and 14 years experience as a department director and vice president in the healthcare industry.

Objectives

After studying the information presented, the reader should be able to:

Describe various uses of health information and their impact on patient care documentation.
Recognize internal and external entities that determine medical record content.
Discuss the most common formats of medical record documentation and list advantages and disadvantages of each.

Resources

Bibliography:
Bruce JAC. Privacy and Confidentiality of Healthcare Information. Chicago, Ill: American Hospital Publishing; 1984:7-18.

Gartee, R. Electronic Health Records. Upper Saddle River, NJ: Pearson Prentice Hall; 2007: 8-10.

George, JE. The emergency department medical record. Emerg Med Clin North Am. 1993; 11:889-903.

Green M and Bowie MJ. Essentials of Health Information Management. Clifton Park, NY: Thomson Delmar Learning: 2005: 93-94

Huffman EK. Health Information Management. 10th ed. Berwyn, Ill: Physicians' Record Company; 1994.

Mastering Documentation. Springhouse, Pa: Springhouse Corporation; 1995.

Pozgar GD. Legal Aspects of Health Care Administration. 3rd ed. Rockville, Md: Aspen Publishers; 1987:113-122.

Southwick AF. The Law of Hospital and Health Care Administration. Ann Arbor, Mich: Health Administration Press; 1978:298-345.

Webliography:
General Info
Medical Records Institute. Home Page: Welcome to the Medical Records Institute. 2006. Available at: http://www.medrecinst.com/. Accessed June 7, 2006.

Public Health
American Public Health Association - APHA. Home Page. 2002. Available at: http://www.apha.org/. Accessed June 7, 2006.

Martindale J. Martindale's Public Health Center Health Science Guide: Public Health Center. 2006. Available at: http://www.martindalecenter.com/PHealth.html. Accessed June 7, 2006.

Goverment Publications
U. S. Department of Health and Human Services, Agency for Healthcare Research and Quality. Medical Errors: The Scope of the Problem. Fact sheet, Publication No. AHRQ 00-P037. February 2000. Available at: http://www.ahrq.gov/qual/errback.htm. Accessed June 7, 2006.

U.S. Department of Health and Human Services. Office of the National Coordinator for Health Information Technology (ONC) Mission. August 19, 2005. Available at: http://www.hhs.gov/healthit/mission.html. Accessed June 7, 2006.

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