Name: ________________________________________
Date: _________________________________________
Procedure 13-3:
Creating a Patient’s Medical Record
Objective: Establish a new medical record file for a patient.
Equipment and Supplies: EHR software; patient registration form; file folder and forms (for paper
records)
Affective Behaviors: Affective behaviors provide a professional approach to a skill that enhances
the patient encounter. These behaviors may also display sensitivity to a patient’s rights and
enhance communication. Pay close attention to these skills, which will be in bold, italicized font.
Skills Assessment Requirements
Read and familiarize yourself with the procedure. Complete each procedure within a reasonable
amount of time, with a minimum of 85% accuracy.
Documentation
Use the area below for any documentation needed to complete the procedure.
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GRADED
TRIAL
# 1
GRADED
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NOTES
Electronic Records
1. Log in to the EHR software using
the username and password
previously created.
2. Select the menu item to create a
new patient or a new chart.
3. Refer to the patient registration
form to complete the patient
information requested on the
screen, such as name, address,
birthdate, and so on.
4. Save the information.
5. Visually confirm that the record
has been created by the EHR
system.
6. Identify the medical record
number. Write it on the patient
registration form.
7. Scan in or link any existing
information, paperwork,
documentation, etc. according to
procedures for the EHR software.
8. Save the medical record and sign
out of the system.
Paper Records
1. For paper medical records,
identify the medical record
number following oce
procedures and write it on the
patient registration form.
2. Insert the patient registration form
in the designated location in the
front of the file.
3. Create a file folder label with the
patient’s medical record number or
name, following oce procedures.
Name: ________________________________________
Date: _________________________________________
POINT VALUE
= 3–6 points
= 7–9 points
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NOTES
4. If using a preassembled chart,
visually check that all the required
forms appear in the chart, in their
proper locations, according to
oce policy.
5. If necessary, collect the
necessary or missing forms and
insert in the designated location
in the chart, according to oce
policy.
6. Insert any existing completed
paperwork for the patient in the
designated location.
7. File the chart, following the filing
protocol outlined in oce policy.
GRADING
Points Earned
Points Possible 114 114
Percent Grade (Points Earned/
Points Possible)
PASS: YES
NO
N/A
YES
NO
N/A
Instructor Sign-O
Instructor: ______________________________________________ Date: _________________________
Name: ________________________________________
Date: _________________________________________
POINT VALUE
= 3–6 points
= 7–9 points
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