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Preparing a Procedure Manual

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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
What is a medical record used for………………………………………..5
Who can document in the chart…………………………………………..6

Chapter 2………………………………………………………………….7
Medical Record Department Responsibilities…………….........................7
Medical Record Departments major functions……………………………7
Retention of Medical Records…………………………………………..8-9
Glossary…………………………………………………………………10
Acknowledgements………………………………………………….......11

Introduction: This procedure manual will help properly train the staff on how to maintain a medical record. This includes medical office assistants, nursing homes, administrators and medical billing specialist. The reason for the manual is for medical/health record workers to develop and manage the records more effectively and efficiently. After reviewing the manual you should be able to: * Identify functions and purpose of a medical record * Understand multiple uses for a medical record * Patient identification and registration procedures * How to tell if new forms are needed in the chart * Release of patient information * How to tell if a chart is complete * Tell who can document in the chart *...

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