10160166Clinical and Business Documentation Techniques
Course Information
Description
Learn guidelines for accurate electronic health record documentation. Applying the Association for Healthcare Documentation Integrity standards, mastery of medical documentation rules for capitalization, measurement and quantitation, abbreviations, grammar and punctuation, reference materials, plurals and possessives, business correspondence formats, and an exploration of specialty standards with an emphasis on quality healthcare documentation.
Total Credits
3
Course Competencies
  1. Punctuate phases and sentences
    Assessment Strategies
    by inserting proper punctuation marks and rules on a worksheet
    by written examination.
    Criteria
    you use reference materials to select proper punctuation
    you list reasons for accurate use of punctuation marks
    you identify grammatical terms for parts of speech
    you write the appropriate punctuation rule
    you insert proper punctuation marks
    written examination demonstrations application of punctuation rules.

  2. Capitalize words correctly
    Assessment Strategies
    by capitalizing words on worksheet prepared in lower case letters
    by written examination.
    Criteria
    you accurately capitalize words
    you recognize when capital letters are required
    you explain special uses of capitalized letters in medical reports
    you use reference materials to check unfamiliar medical/business terms
    written examination demonstrates application of capitalization rules.

  3. Transcribe numbers and figures
    Assessment Strategies
    by typing figures, symbols, and abbreviations on a medical document
    by written examination.
    Criteria
    you explain when a number should be typed as a figure, spelled out, or as a roman numeral
    you type medical and business symbols and abbreviations appropriately
    you demonstrate accurate typing of material containing numbers, symbols, and abbreviations in medical writing
    you recognize and correctly use metric abbreviations
    written examination demonstrates application of transcribing numbers and figures.

  4. Compose business letters
    Assessment Strategies
    by producing a quality business letter
    by producing each of the basic formats of letters
    Written Objective Test
    Criteria
    you produce a quality business letter
    you demonstrate professional business letter formats
    you prepare a two-page letter accurately
    written examination demonstrates application of correct letter formats and letter parts.

  5. Proofread written communication for quality assurance
    Assessment Strategies
    by proofreading documents and inserting standard proofreader's symbols
    by correcting transcripts
    Criteria
    you illustrate the importance of proofreading documents
    you use and recognize proofreader's symbols
    you proofread and correct transcripts

  6. Use resources
    Assessment Strategies
    by researching medical information via textbooks
    by researching medical information via internet
    by creating a personal reference binder
    Criteria
    you utilize resources appropriately and efficiently
    you compare and contrast book references and internet references
    you efficiently find missing medical information to assure quality reports
    personal reference binder becomes an "Information Station" containing reference information gathered from courses at Madison College to be used on the job.

  7. End words correctly
    Assessment Strategies
    by correctly making medical and English words plural
    by constructing correct plural and adjective endings of medical terms
    by written examination.
    Criteria
    you explain rules for making medical and English words plural
    you identify adjectives and noun endings
    you construct plural and adjective endings of medical terms
    written examination demonstrates application of medical term endings

  8. Use antonyms, eponyms, homonyms
    Assessment Strategies
    by correctly transcribing antonyms, eponyms, and homonyms
    by written examination
    Criteria
    you correctly use antonyms, eponyms, and homonyms
    you correctly punctuate eponyms
    you correctly capitalize eponyms
    written examination demonstrates application of correct use of antonyms, eponyms, and homonyms

  9. Analyze professional organizations
    Assessment Strategies
    by exploring professional organization websites
    by corresponding with a professional in the field
    by learning about certification options for the field
    Criteria
    you identify professional organizations for medical transcriptionists
    you correspond with an E-Buddy (professional transcriptionist)
    you complete professional organization worksheet activity