Medical Documentation

This course is intended for those who wish to expand their knowledge of medical documentation. The goal of this course is to present material on an introductory level covering multiple facets of the subject, as outlined in the modules below. Identify and understand different types of documentation and abbreviations Identify and understand the role of the medical professional in patient record keeping Understand and discuss common errors in medical documentation and how to avoid them Understand and discuss patient safety as it relates to medical documentation Review and be able to implement different guidelines for medical documentation Understand the history of medical record keeping and implications of implementing electronic records List at least 3 of the Joint Commission ‘Do Not Use’ list Review and understand the various components of the patient record Review and understand legal aspects, regulations, and security measures of medical documentation