MEDICAL DOCUMENTATION

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Learning Outcomes

Defines the concepts of data, information, and documents
Explains the concepts of data, data types, and data sets in health services
Explains the areas of use of electronic patient records
Defines the concepts of archive, archiving, medical archives, and medical records
Defines the patient records archive
Identifies institutions responsible for document management at the national level
Defines the concept of medical records
Lists the characteristics required of a medical records professional
Identifies the users of medical records
Explains the concept and purposes of hospital information systems
Defines the integrated hospital automation system and its components
Provides information on digital hospital projects in Turkey and worldwide
Explains the historical development of medical documents
Explains the concepts of patient records and electronic patient records
Compares paper-based and electronic patient record systems
Evaluates the importance of patient records from the perspectives of patients, institutions, and society
Explains the areas of use of patient records
Explains the organization, numbering, and filing methods of patient records
Defines the basic concepts related to the patient records archive
Explains the structure and operation of the patient records archive
Explains the architectural and administrative characteristics of the patient records archive
Compares the organizational models applied in the patient records archive
Explains the relationship of the patient records archive with other departments
Explains the administrative and legal responsibilities related to health records
Explains the legal regulations regarding the protection of personal health data
Explains the principles of confidentiality, security, and privacy in health records
Evaluates the use of patient records as legal evidence
Explains the retention periods of health records
Understands the importance of health records
Understands the importance of disease classification
Identifies international disease classification systems
Explains the structure and uses of the ICD system
Demonstrates knowledge and skills in applying clinical coding principles
Explains the rules and techniques of official correspondence
Explains the functioning of the Electronic Document Management System (EDMS)
Defines the types of medical reports
Explains the process of preparing forensic reports
Understands the basic concepts related to medical documentation
Explains the purpose of documentation
Explains the concept of quality in documentation
Evaluates the factors affecting the quality of medical documents
Explains the impact of medical records on the quality of health care services
Understands the contribution of medical records to health care services
Defines non-inpatient health care facilities
Explains data collection processes in non-inpatient health care facilities
Defines the medical documents used in primary health care facilities
Explains medical documentation practices in public health units
Explains the medical documentation process in 112 Emergency Medical Services