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Name: __________________________________________ Date: _____________ Score: _____________
Procedure 26–1 Create and Organize a Patient’s Medical Record
MA.A.1.8.a Gather and process documents
CAAHEP Core Curriculum
VI.C.4 Define types of information contained in the patient’s medical record
VI.C.5 Identify methods of organizing the patient’s medical record based on: (a) problem-oriented medical
record (POMR) and (b) source-oriented medical record (SOMR)
VI.C.6 Identify equipment and supplies needed for medical records in order to: (a) Create, (b) Maintain, and (c)
VI.C.7 Describe filing indexing rules
VI.P.3 Create a patient’s medical record
VI.P.4 Organize a patient’s medical record
VI.P.6 Utilize an EMR
VI.P.7 Input patient data utilizing a practice management system
Task: Following the steps listed in the procedure, prepare an accurate and complete patient chart to
submit to the provider for final review.
Supplies & Conditions: Chart or folder, patient records, privacy forms, tabs (if using electronic records: computer and
Standards: A maximum of three attempts may be used to complete the task. The time limit for each attempt
is 10 minutes, with a minimum score of 70 percent. Scoring: Determine student’s score by
dividing points awarded by total points possible and multiplying results by 100.
Evaluator Signature: Date:
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