Medical Documentation I
Syllabus
Course objective
The aim of this course is to introduce the medical documentation processes, records, and systems used in healthcare institutions; and to equip students with the skills to properly and effectively prepare, archive, and analyze patient files, reports, consent forms, and other healthcare documents.
Course content
The course covers the definition, importance, and historical development of medical documentation; the structure of patient files; legal and ethical aspects of medical records; outpatient and emergency department documents; laboratory and radiology reports; special case documents (birth, disability, work accident, etc.); and medical reports.
Learning outcomes
- Explains the scope, importance, and historical development of medical documentation.
- Identifies the characteristics of patient files and documents used in healthcare institutions.
- Evaluates the legal and ethical aspects of medical records.
- Prepares and archives outpatient, emergency, laboratory, radiology, and special case documents.
- Applies principles of effective communication, confidentiality, and accuracy in medical documentation processes.
Weekly topics
| Week | Topic |
|---|---|
| 1 | Definition, scope, and historical development of medical documentation |
| 2 | Importance of documentation in healthcare institutions and basic principles |
| 3 | Patient files and their characteristics |
| 4 | Legal and ethical aspects of medical records (patient rights, responsibilities) |
| 5 | Types of medical records (epicrisis, anamnesis, progress notes, medical reports, consent forms, consultation, etc.) |
| 6 | Emergency department documents (first aid form, consents, referral documents) |
| 7 | Outpatient clinic documents (examination form, prescription, test request) |
| 8 | Midterm Exam Exam |
| 9 | Inpatient documents (admission form, nursing observation form, treatment schedules) |
| 10 | Surgery and intervention documents (operation note, anesthesia form, intervention consent) |
| 11 | Laboratory documents (test request forms, result reports) |
| 12 | Radiology and imaging documents (requests, reports, consents) |
| 13 | Consultation and epicrisis documents |
| 14 | Special case documents I (birth, disability, work accident, etc.) |
| 15 | Special case documents II (medical reports: incapacity report, health board reports, drug report, medical supply report, etc.) |
| 16 | Final exam Exam |
| 17 | Final Exam Exam |
Assessment
| Activity | Number | Weight |
|---|---|---|
| Mid-terms | 1 | 40% |
| Final examination | 1 | 60% |
| Total | 2 | 100% |
Course materials
- Aylanur Ataklı, Aslan Kaplan. Tıbbi Dokümantasyon Ve Sekrterlik. Güneş Tıp Kitabevleri.
- Tengilimoğlu, D. ve Nilgün, Ç. (2003). Yönetici ve Tıp sekreterliği. Ankara: Seçkin Yayıncılık.
This syllabus is taken from the KBU Bologna information package. Bologna information package ↗