Preparing a Procedure Manual Essay

1135 Words Oct 9th, 2012 5 Pages
ENGL205-1201A-06
Technical Writing and Speaking
Phase 4 Individual Project
Preparing a Procedure Manual
Kelley Auxier
February 6, 2012

MEDICAL RECORD PROCEDURES
HEARTLAND HEALTH COMMUNICATIONS

Volume 2
Kelley Auxier
Heartland Health Communications
Revised
February 7, 2012

Table of Contents

Heartland Health Communications……………………………..1
Table of Contents……………………………………………………….2
Mission Statement……………………………………………………...3
Objectives………………………………………………………………….3

Chapter 1……………………………………………………………………….4
Purpose and Function of a Health Record……………………………………..4 * Patient care management * Financial and administrative processes * Patient self-management
Maintenance of the health record………………………………………...5
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* Illnesses and treatments * Communication * Care for patient * Legal matters * Health statistics
Page 7 – 4 major sections of a medical record * Administrative * Legal data * Financial data * Clinical data
Who can document in the chart? * Physicians * Nurses * Anyone that is licensed and treating the patient
Page 8 – Medical Record Department Responsibilities
Page 9 – Retention of medical records * How long a record should be kept? * What content should be kept permanently?
Page 10 – Glossary
Page 11 – Acknowledgements

Abstract: The contents of this procedure manual is to help better understand the proper steps to maintain the health record of every patient we have within our facility with the highest of accuracy and in an efficient amount of time. The records are a history of a person’s health and are very relied

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