Medical Documentation Process (TDYN219)
The course aims to teach the core principles of medical documentation, with its effects on the health services, the analysis of documents used in health centers, the qualitative and quantitative analysis of medical records, documentation development processes and analysis of administrative records, polyclinic documentation, intensive care documentation, anesthesia documentation, laboratory documentation and records, pathology, radiology, nursing service documentation, the roles of health information managers, the medical records processes, forming electronic indexes, different methods of obtaining data from medical records, the legal processes of medical records, electronic format of handling patient processes, discharge processes, electronic patient operation index, the privacy policies of medical documents and the policy of announcing the detalis in medical records, the duration of storing medical documents, the accountability, reliability, privacy, confidentiality and declaration of the data, factors affecting the quality of medical records, usage of medical records in health services, generating health statistics, the effect of records on patient services, patient safety, accreditation process, the relation between medical records and payment system, the effect of patient record on sickness costs, the impact of medical records on the communication between health staff.