Medical Records    

 

 

 

Guide to Medical Records

[A] Introduction

[B] Determining if the record is complete

    1. Components of the Hospital
    2. Components of Doctor's Office

[C] Hospital Admission Records

    1. Hospital Admission Sheet
    2. General Consent to Treatment 'Assignment of Insurance Benefits
    3. Checklist : Question for Defense - appointed Physician

[D] Doctor's and Nurses ' Admission Histories and Examinations

    1. Components of Medical, Family, and Social Histories
    2. Physical Examination
    3. Dealing with Defense - Oriented Doctors
    4. Nurse's Assessment

[E] Doctors Progress Notes and Nurses' daily Notes

    1. The S.O.A.P. Method
    2. What Progress Notes Should Include
    3. What Daily Notes Should Include

[F] Surgery and special Procedure Records

    1. Special Procedure Consent Forms
    2. Surgery or Special Procedure Reports
    3. Anesthesia Records
    4. Operating Room Nursing Notes
    5. Recovery Room Records

[G] Other Components of Hospital Records

    1. Emergency Room Records
    2. Graph of vital signs
    3. Medication and Intake and output Records
    4. Doctor's Orders and Consultation Reports
    5. Electronic Fetal Monitor Records
    6. Electronic Records
    7. Department Studies
    1. Radiology Department Studies
    2. Laboratory Studies
    3. Autopsy Report
    4. Incident Report

[H] Doctors' and Nurses' Discharge Summaries

[I] Medical Records Status Report and activity Log

[J] Chronological Analysis

Sample " Chronological Analysis

[K] Case Scenarios demonstrating the importance of Medical Records

Conclusion

 

*****Lecture seminar for this course is 4.0 hours for Continuing Education (CE).  The course provides the student with knowledge of reading medical records as well as analyzing  the treatment  to determine if the  injuries are accident related.  This is one of the first stages  in reconstruction of injuries.  The course take an depth understanding of  medical terminology, which provides the student with a thorough  understanding  of medical procedures  and stages of recovery . Course study for a Professional Designation  requires18 hours study time.

 

 

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