Clinical and Business Documentation Techniques | Madison College Outline of Instruction

10160166 Clinical 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

Course Competencies (Course Outcomes)

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.
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.
Transcribe numbers, figures, abbreviations, symbols

Assessment Strategies

Transcribe numbers, figures, abbreviations, and symbols correctly in clinical 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.
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.
Proofread written communication for quality assurance

Assessment Strategies

by proofreading documents and inserting comments

by correcting transcripts

Criteria

you illustrate the importance of proofreading documents

you proofread and correct transcripts
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
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
Analyze professional organizations

Assessment Strategies

by exploring professional organization websites

by learning about certification options for the field

Criteria

you identify professional organizations for medical transcriptionists

you complete professional organization worksheet activity
Explore research and manuscript documentation

Assessment Strategies

Dissect a full medical article from a scientific journal

Criteria

Explore medical scientific journals

Demonstrate manuscript parts

Review author submission guidelines