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Butler Community College
JoEva Blair
Nursing, Allied Health and Early Childhood Education Division

Spring, 1994

Course Outline
MEDICAL RECORDS FOR LONG TERM CARE

COURSE DESCRIPTION:

AH205. Medical Records for Long Term Care. 3 hours credit. This course provides the student with the knowledge and skills needed to organize a medical records department under the supervision of an Accredited Medical Records Professional in a long-term care setting. Topics include terminology and documentation requirements, confidentiality, legal aspects and rules and regulations of Kansas Department of Health and Environment.

TEXTBOOK:

None. Printed material will be provided to each student.

COURSE OBJECTIVES:

At the completion of this course, the student should be able to:

1. Define the role of a medical records designee in a long term care facility

2. Explain federal and state regulations regarding record keeping in long term care

3. Identify aspects of confidentiality

4. Discuss the organization of information in the health record

5. Understand medical terminology

6. Understand the role and function of other departments in the long term care facility.

TOPICAL OUTLINE OF UNITS:

I. Introduction to and organization of long term care

a. Identify the major health care delivery systems operating in the United States

b. Identify the difference between LTC, acute care, ambulatory and home care

c. Understand organizational structure of LTC facilities

d. Distinguish between licensure and certification.

II. Medical Terminology

a. Use a medical dictionary

b. Analyze word parts to define the meaning of medical terms composed of familiar roots, prefixes and suffixes.

III. Disease Classification

a. Code a list of diseases using the ICD 9 CM Manual

b. Describe the value of indexing diseases

c. Demonstrate how to use the card method for indexing diseases

e. Demonstrate a knowledge of how to use the ledger method for disease indexing.

IV. Organization of Health Record Information

a. Identify common forms found in a health record

b. Describe the differences between records used in acute care, ambulatory care and long term care

c. List the basic information found in a face sheet

d. Differentiate between consent and authorization

e. Explain the term "informed consent"

f. Identify six of the eight components of a database for residents in a LTC facility

g. Identify two reasons an overall plan of care enhances quality of care for residents

h. Explain the purpose of a discharge plan

i. Identify the uses of common forms found in a health record

j. Identify requirements for accurate documentation on medication and treatment records

k. State the reasons for analysis of health records

l. Differentiate between qualitative and quantitative analysis of records

m. Identify the responsibilities of members of the health care team for different aspects of the health care record

n. Place elements of a health record into a desired format.

V. Admitting Procedures

a. Using a checklist, determine if all required admitting information is present on the record

b. Assign resident numbers according to a unit and serial numbering system

c. State the value of the master resident index

d. Label forms in chart with name and number of resident

e. Demonstrate how to set up a tickler file system.

VI. Overall Plans of Care

a. Identify the types of documentation required in an overall plan of care for each discipline

b. Explain how a resident's overall plan of care can be used to show evidence of care rendered

c. State requirements for discharge planning

d. State the reason for analysis of health records

e. Differentiate between qualitative and quantitative analysis of records

f. Identify the responsibilities of members of the health care team for different aspects of the health care record

g. Place elements of a health record into a desired format

h. Explain how a resident's overall plan of care can be used to show evidence of care rendered

i. State requirements for discharge planning.

VII. Monitoring and Analyzing the Health Record

a. Perform an analysis of a health record

b. Use a deficiency slip to indicate an error or omission in documentation

c. Explain how to set up a tickler file

d. Explain how monitoring and analyzing the health record contributes to quality patient care.

VIII Legal Aspects of the Health Record

a. Determine who can give proper consent for treatment

b. Differentiate between guardian and conservator

c. Assess the validity of an authorization to release confidential information

d. Identify the retention requirements in Kansas.

METHODS OF INSTRUCTION:

The following teaching/learning activities will assist students to achieve course objectives: lecture, instructor-led discussion, assignments, audiovisuals, and review of medical records in a long term care facility.

METHODS OF EVALUATION:

Three quizzes will be given during the course, plus a final exam. Grade determination will be dependent upon exams, assignments, and attendance.