OFFT 2041 - Healthcare Documentation Fundamentals

• Healthcare documentation
• Body system terminology
• Document formatting
• English spelling and grammar
• Organization’s code of ethics
• Editing of speech-recognized documents

1. define the importance of accurate and complete healthcare documentation.
2. identify the uses of healthcare documentation.
3. define the content and purpose of the various medical reports.
4. identify the parts of a provider note including the history of present illness, review of systems, past medical, social, and family history, and physical exam and vital signs.
5. incorporate medical terminology into medical documents using a body system approach.
6. demonstrate the use of language skills and medical knowledge to document, edit, revise, and clarify while editing or proofreading dictation.
7. demonstrate medical editing of speech-recognized reports.
8. identify professional and ethical conduct.
9. use medical references and other resources while proofreading, editing, and reviewing reports.
10. investigate careers in healthcare documentation quality and editing.

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