
This course produces and transcribes entry-level medical documents from dictation or from handwritten material (e.g. medical chart notes, progress notes, history and physical examination reports, and miscellaneous documentation). Emphasis is placed on the importance of editing and proofreading within specified deadlines along with the medical/legal implications resulting from inaccurately produced medical documentation.
Course Content
Course Outline
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Maintaining Medical/Health records
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Information Clerk
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The Health Information Management Department
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Number and Filing Methods
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Processing Medical Records
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Assembly of the Medical Record
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Analysis of the Record
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Physician Incomplete Area
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Confidentiality and Release of Information
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Other Medical Record Clerk Functions