Portland Community College | Portland, Oregon

Upon completion of this course students should be able to:

1. Describe and validate the documentation in the health record to ensure it supports the diagnosis and reflects the patient's progress, clinical findings, and discharge status.
2. Validate that outpatient and alternative care setting documentation in the health record is timely, complete and accurate.
3. Describe a complete outpatient and alternative care setting health record according to organizational policies, external regulations and standards.

Students will demonstrate these learning outcomes by these tasks conducted individually and in cooperation with outer students:

1. Answer theoretical and application questions on information covered in the lecture, graded assignments and reading assignments.
2. Locate data requirements in federal, state, and accrediting bodies documentation.

To complete the outcomes in this course students must have skills in:

• Federal and state regulations for health records
• Joint Commission documentation standards
• Accrediting agencies documentation standards
• Medical terminology