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Best Practices for Reading and Understanding Different Parts of a Medical Record

Gain a better understanding of medical records and what types of information they contain.

This topic will help you be able to organize, read and understand the information contained in various parts of the medical record in an efficient manner. You will be able to identify the forms in which medical records are contained as well as the contents of medical records. The material will help you with organizing medical records as well as how to understand each part of the medical record. Finally the information will help you be able to systematically follow the admission process, diagnosis, treatment(s) and discharge of clients.

89 minutes
Certificate of Completion
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Why Lorman?

Over 34 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Agenda

Medical Records: Who, What, Why?

  • Medical Records From Each Stakeholder's Perspective
  • The Clinical Medical Record
  • Everything But the Clinical

Clinical Records: Who, When, Where, and How

  • Clinicians and Their Elves
  • Components and Data Sources
  • Four Methods for Clinical Documentation

Outcomes

  • Clinical
  • Financial
  • Social and Other Determinants of Health

Business and Medical Records

  • Reputation
  • Referrals
  • Payments

Sharing Medical Records

  • Research
  • Litigation
  • Sharing
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Why Lorman?

Over 34 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Credits

OnDemand Course

This course was last revised on April 22, 2021.

Call 1-866-352-9540 for further credit information.

  • AHIMA 1.5 including Informatics, Analytics, and Data Use 1.5
     
  • This program has been approved for 1.5 continuing education units for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting prior approval from AHIMA does not constitute endorsement of the program content or its program sponsor.
     

This program does NOT qualify, nor meet the National Standard for NASBA accreditation.

MP3 Download

This program does NOT qualify, nor meet the National Standard for NASBA accreditation.

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Why Lorman?

Over 34 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Faculty

James Maisel, M.D.

James Maisel, M.D.

ZyDoc Medical Transcription, Retina Group of NY

  • CEO and founder of ZyDoc Medical Transcription, Retina Group of NY
  • Medical records, transcription, practice management, speech recognition, cloud platforms, security, EHRs, interoperability, diabetes, retina, pharma
  • Numerous industry presentations in medical informatics, speech recognition, NLP, and standards
  • Sold a prototype EHR to DOD, 1994; licensed medical language models to Dragon NaturallySpeaking Medical, 2000; introduced NLP data extraction from unstructured text, 2010; published NIH-Columbia Sponsored Landmark EHR Usability Study with NLP data, 2016; and #2 industry ranking in medical transcription, 2020, with #6 cloud platform
  • Former chair HOST prior to HIMSS merger, Congressional Recognition Award, co-chair World Diabetic Congress, JDRF Humanitarian Year, Gift of Sight and Anton Banko awards
  • M.D. New York Medical College
  • Vitreoretinal Surgical Fellowship at NY Presbyterian-Cornell Medical Center
  • CEWIT incubator, Stony Brook, NY
  • Can be contacted at 800-546-5633 or [email protected]
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Why Lorman?

Over 34 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

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Product ID: 407618
Published 2021
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