Thursday, 09th February, 2023

Medical Documents and Records Course

Healthcare Quality Management Courses.| Medical Documents and Records Course.

Provide the trainees with knowledge and skills regarding medical documentation, besides change trainees’ attitude toward practice documentation in different health care settings.

Course Objectives

  • Define medical documentation.
  • List the reasons, barriers and tools for documentation.
  • Identify the guidelines of medical documentation.
  • Recognize methods of medical documentation.
  • Compare between different tools of medical documentation.
  • Identify legal aspects of documentation.
  • Explain the use of technology in documentation.
  • Enumerate types of electronic documentation.
  • Apply medical documentation tools.
  • Apply medical documentation methods.
  • Introduce electronic medical documentation to different health care settings.

Course Contents

  • Definition of Medical Documentation.
  • Purposes of Documentation.
  • Research, auditing, and evaluation of medical documentation.
  • Ethical and legal issues of documentation.
  • Security and confidentiality of medical information.
  • US, UK, German law and customs of medical documentation.
  • Guidelines for Documentation.
  • Principles of Effective Documentation.
  • Elements of Effective Documentation.
  • Skills Used in Documentation.
  • Methods of medical Documentation.
  • Tools for medical documentation.
  • Introducing new documentation system.
  • Barriers to Medical Documentation.
  • Hospital Information System.
  • North American, European, Asian Hospital Information Systems.
  • Electronic Documentation.
  • Guidelines for nurses using electronic health records.
  • Types of Electronic Documentation.


  • 3 Days / 15 Hrs.


  • Certificate approved by The AASTMT

Teaching Language

  • English / Arabic


  • Productivity and Quality Institute or Company Headquarters

Instructor/Trainer Qualification

  • Professorial lecturer in Hospital Administration and Quality Assurance in healthcare field.