Name: ________________________________________
Date: _________________________________________
Procedure 13-4:
Organizing a Patient’s Medical Record
Objective: Update the patient’s medical record by filing new information in the correct place and
correct record.
Equipment and Supplies: Patient medical record; assorted documents (paper or electronic) for
filing in record
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
TRIAL
# 2
NOTES
Electronic Records
1. Log in to the EHR with your
username and password.
2. Access the record of the desired
patient. Confirm the medical
record number, patient name,
address, and date of birth.
3. Access the menu for importing or
linking external documents.
4. Follow the onscreen prompts or
menu selections to scan in paper
documents or link to existing
electronic files. Ensure that each
file is associated with the correct
purpose, such as laboratory
results or consultation reports.
5. When prompted for a date for the
record, enter the date the report
was issued, not today’s current
date. The EHR will automatically
sort the records in chronological
or reverse chronological order, as
designated by the user.
6. Verify that all documents have
been scanned or imported. Exit
the patient’s record.
Paper Records
1. Verify that you have the correct
patient record for the patient
documents you have been given.
Confirm medical record number,
patient name, address, and date
of birth.
POINT VALUE
= 3–6 points
= 7–9 points
Name: ________________________________________
Date: _________________________________________
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GRADED
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# 1
GRADED
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NOTES
2. File documents in reverse
chronological order with the most
recent record at the beginning of
the section, in the correct areas of
the file, according to your facility
policy. For example, file laboratory
reports with other laboratory
reports within the lab section, and
with the most recent report on
top.
3. Return the medical record to the
correct place in alphabetic or
numeric order with other patient
files.
GRADING
Points Earned
Points Possible 69 69
Percent Grade (Points Earned/
Points Possible)
PASS: YES
NO
N/A
YES
NO
N/A
Instructor Sign-O
Instructor: ______________________________________________ Date: _________________________
POINT VALUE
= 3–6 points
= 7–9 points
Name: ________________________________________
Date: _________________________________________
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