Medical Documentation

Catalog description

This technical writing and writing intensive course will provide students with fundamental principles of medical documentation. Topics include general principles of medical documentation, documentation of a patient history and physical, clinical interventions, responses to interventions, and transfer of care. The course will cover legal documentation topics including, confidentiality, privacy, HIPPA, documentation of incident reports, documenting patients who decline medical advice and/or treatments, and creating a legally defensible report. The course will cover principles of electronic record keeping and cumulate in the systematic creation of the integrated prehospital patient care report. Fee Information: Lab fee required. Share this Page Facebook this Page (opens a new window) Tweet this Page (opens a new window) Print (opens a new window) Help (opens a new window)