Fillable Competency Checklist Procedure 261 Create and Organize a (Cengage)

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Competency Checklist Procedure 261 Create and Organize a (Cengage)

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© 2017 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.
Name: __________________________________________ Date: _____________ Score: _____________
Competency Checklist
Procedure 26–1 Create and Organize a Patient’s Medical Record
ABHES Curriculum
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)
Store
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
EHR program).
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.
EVALUATION
Evaluator Signature: Date:
Evaluator Comments:
445
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© 2017 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.
Name: __________________________________________ Date: _____________ Score: _____________
Procedure 26–1 Steps
Start Time: End Time: Total Time:
Steps
Possible
Points
First
Attempt
Second
Attempt
Third
Attempt
1. Prepare chart or folder for patient (electronic or paper).
Verify accurate spelling of name. Include demographics,
insurance information, privacy forms, and emergency
contact information.
15
2. Retrieve and compile available reports and information.
Verify that all records are for the correct patient before
including in the record.
15
3. Sort and organize records by type: operative notes,
progress notes from various providers, laboratory
reports, radiology, medication flow sheets,
immunization records, and so on. (If using electronic
records, organize the documents and enter information
or scan to correct tab in the EHR.)
15
4. Verify accuracy and completeness and submit to
provider for final review.
15
Points Awarded / Points Possible _____/
60
446
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Competency Checklist Procedure 261 Create and Organize a (Cengage)

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Completed 6 June 2021

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