Location

Productivity and Quality Institute - Alexandria

Objectives

• At the end of this Course, the trainees will be able to:• 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.

Outcomes

• Identify different tools of medical documentation• Introduce electronic medical documentation to different health care settings.• Describe medical documentation as legal and ethical system

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: