Medical Assistant Model

Units:

Tags

Unit Industry Sector
Health Science and Medical Technology

Unit Originally Created By: Karen Dalton-Wemp

The Patient Record

Part of Course: Medical Assistant Model

Unit Overview / Details

This unit describes elements of a patient's chart and the types of medical records that are inclued in the  patient's record.

Instructional Time

Classroom
8 Hours
Community Classroom
20 Hours
CVE
20 Hours

Content / Concepts

A.         The data base

1.        Obtaining a patient history

2.        Rules of charting

3.        Legal aspects of the patient's chart

B.         Organization of the medical record

1.        Types of forms used

2.        Order of forms within the record

3.        The problem-oriented medical record

4.        SOAP (Subjective/Objective Assessment Plan) Assessment

Standards

Lessons in this Unit

  • How to use SOAP

    This lesson is to prepare the student to effectively document in a clinical record using a SOAP format, appropriate medical terminolgy and abbreviations.

    full class period
    57 Minutes