Students Learn to Document for Purposes of Medical Record Keeping

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Gayatri Sirohi, Highline Community College
Summary: Students learn to document for purposes of medical record keeping.
Student Learning Objectives for English 101:
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adapt and control the voice and style of their writing to different purposes, audiences, and genres.
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identify the main and subordinate ideas in a written work and summarize the ideas in their own
words in order to represent another text fairly and completely.
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integrate their own ideas with those from a variety of written, oral, and visual texts through
summary, paraphrase, or direct quotation.

define and avoid plagiarism by distinguishing their own words and ideas from those of sources; to
cite and document sources at a basic level.
Student Learning Objectives for HEAL students:
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Communicate (written, verbal and nonverbal) effectively with diverse patients and staff.
Document within legal and ethical boundaries.
Explain general office policies and establish and maintain patient records.
Context: Before this assignment was developed students did a paraphrase of an academic journal article
to understand how to cite, paraphrase, etc. (see English 101 outcomes above). However, discussing this
assignment with the HEAL faculty it was clear to me that what the HEAL students needed was an
exercise in documentation where similar skills can be practiced. The next version of the assignment
asked them to document a medical scenario and most students did poorly since they could not
differentiate that the audience and purpose for such an exercise is very different from the usual one for an
English 101 essay. Instructor Wendy Swyt and I then developed this new version with an appropriate
rubric which worked out pretty well.
Instructions:
This week, you'll document a new medical scenario for a grade. However, we are going to add to the
assignment this week because we want you to pay attention to different writing situations. Not all
situations use medical documentation. For example, Group Health wants descriptions typed out with no
abbreviations. And to write essays for college classes, you need to use complete sentences not
abbreviations and fragmented details.
To stress the different rhetorical contexts for writing and the uses of language in those contexts, we want
you to write out the scenario in three different ways. Same scenario, just write it in three different ways
(analogy: you have a chicken but you can prepare it in different ways, adding different spices, so that it
works in different contexts. Same chicken, different tastes!).
The Assignment:
Watch the video of the medical issue at the bottom of this page.
Then write it up in three different ways:
1) Write it out in medical documentation: Remember, medical documentation uses abbreviated sentences
and approved acronyms unlike other English exercises. Follow this protocol as detailed in the
documentation samples.
2) Write it out in a paragraph of standard edited English (no abbreviations or sentence fragments -- use
complete sentences and good grammar). Pretend you are Atul Gawande describing this situation in a
paragraph.
3) Write it as a poem. :) This is the fun one! You can make it rhyme or just focus on key images in
broken lines. (see the sample)
Tips on doing this:
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Review the Dos and Don't of documentation from last week.
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Attach it as a word doc.
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Click here for a sample.
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Review the rubric below before submitting your assignment
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