Curriculum to Accompany
Medical Assisting:
Administrative and Clinical Competencies,
6th Edition
Course:
Facility and Records Management
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Curriculum to Accompany Medical Assisting: Administrative and
Clinical Competencies, 6th Edition
Course: Facility and Records Management
Contents
Part A: Preparing for the Day
Part B: The Patient’s Medical Record
Part C: Filing
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Curriculum to Accompany Medical Assisting: Administrative and
Clinical Competencies, 6th Edition
Course: Facility and Records Management
Course Overview
This module deals with concepts and duties assigned to a medical assistant in the
administrative realm. Having patients’ charts ready for the day, preparing the office area
for the scheduled patients, and opening/closing the office are all part of being an efficient
medical assistant. When working with patients’ charts, one needs to pay close attention
to the legal documents that compose the medical record such as patient information
forms, chart notes, lab and x-ray reports, and any correspondence from other providers.
It is imperative that each patient’s medical record be current, available, and organized
properly. Again, confidentiality of the medical record as mandated by HIPAA must be
observed.
Resource List
Textbook: Thomson Delmar Learning’s Medical Assistant: Administrative and Clinical
Competencies, Sixth Edition, by Lucille Keir, Barbara Wise, Connie Krebs, and Cathy
Kelley-Arney. © 2007, Thomson Delmar Learning, ISBN 1-4180-6633-8. Chapter 7.
Student CD-ROM: CD-ROM that accompanies Thomson Delmar Learning’s Medical
Assistant: Administrative and Clinical Competencies, Sixth Edition. This CD-ROM
contains StudyWARE, The Critical Thinking Challenge, and an Audio Library.
Workbook: Workbook to accompany Thomson Delmar Learning’s Medical Assistant:
Administrative and Clinical Competencies, Sixth Edition, by Lucille Keir, Barbara Wise,
Connie Krebs, and Cathy Kelley-Arney. © 2007, Thomson Delmar Learning, ISBN 14180-3267-0. Chapter 7.
Instructor’s Materials: Instructor’s Resource Manual to accompany Thomson Delmar
Learning’s Medical Assistant: Administrative and Clinical Competencies, Sixth Edition,
by Lucille Keir, Barbara Wise, Connie Krebs, and Cathy Kelley-Arney. © 2007,
Thomson Delmar Learning, ISBN 1-4180-3268-9.
Instructor’s CD-ROM: Electronic Classroom Manager to accompany Thomson Delmar
Learning’s Medical Assistant: Administrative and Clinical Competencies, Sixth Edition,
by Lucille Keir, Barbara Wise, Connie Krebs, and Cathy Kelley-Arney. © 2007,
Thomson Delmar Learning, ISBN 1-4180-3269-2.
DVD: Thomson Delmar Learning’s Skills and Procedures for Medical Assistants DVD
Series. Program 1, Administrative Skills. Series ISBN 1-4018-3868-5.
The Internet: It is strongly recommended that faculty and learners alike have a working
knowledge of the Internet.
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Equipment List
1. Multimedia projector
2. Computer with Internet access
3. Multimedia equipment
4. AAMA credentialing information
5. AMT credentialing information
6. DVD player
CAAHEP content
III.C.1.f(1)
Basic medical assisting clerical functions
III.C.1.f(4)
Operational functions
ABHES content
VI.B.1.b(7)(a)
Manual and computerized records management
VI.B.1.b(7)(e)
Reception, public and interpersonal relations
VI.B.1.b(7)(f)
Office safety and security
CAAHEP competencies
III.C.3.a(1)(c)
Organize a patient’s medical record
III.C.3.a(1)(d)
File medical records
ABHES competencies
VI.B.1.a(3)(b)
Prepare and maintain medical records
VI.B.1.a(5)(c)
Use appropriate guidelines when releasing records or information
VI.B.1.a(5)(h)
Perform risk management procedures
VI.B.1.a(6)(a)
Maintain the physical plant
VI.B.1.a(6)(f)
Exercise efficient time management
Learning Activities
(HW) Terminology Notebook. Assign chapter for reading and have students define key
terms and retain in a key term notebook for future reference.
(ICD) Discuss why it is important to prepare the waiting room and examination areas
(ICA) Complete Procedure 7-1.
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(ICA) Complete Procedure 7-2; attach the patient information form as the work product
to the performance evaluation checklist.
(ICA) Complete Procedure 7-3.
(HW) Chapter 7, Unit 1 Workbook Assignment Sheet.
(ICD) Talk about the impact of HIPAA for small offices as contrasted to larger medical
settings.
(ICA) Show a DVD clip—“Administrative and clinical sections of the medical record”
from Program 1: Administrative Skills (Skills and Procedures series).
(ICA) Obtain blank patient charts and inserts and have the students to organize them for
medical records.
(ICA) Provide the student at least one scenario to chart in the SOAP format.
(HW) Activity. Complete Activity 1 on page 213 of the text.
(HW) Chapter 7, Unit 2 Workbook Assignment Sheet.
(ICA) Prior to completing Procedure 7-4, give the student at least ten words to place in
alphabetical order as practice.
(ICA) Complete Procedure 7-4.
(ICA) Complete Procedure 7-5.
(ICA) Complete Procedure 7-6.
(ICA) Complete Procedure 7-7.
(HW) Have the student to research the state law for the length of time medical records
must be retained for your state.
(HW) Chapter 7, Unit 3 Workbook Assignment Sheet.
(HW) The Critical Thinking Challenge, page 212.
(HW) The StudyWare Challenge, Chapter 7. Have students take the Quiz in “Quiz
Mode” and either email their scores to the instructor, or print the scores to turn in.
(ICA) Following review of the chapter and homework assignments, give a quiz on this
chapter that includes the content and competencies listed for CAAHEP and ABHES.
Part A: Preparing for the Day
Learning Objectives
Cognitive
1. Define the key terms presented in the unit.
2. List five things to check in the reception room environment.
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3. List four tasks to perform prior to opening the office besides checking the
reception area.
4. Explain why having a receptionist is important.
5. Live at least five responsibilities for a receptionist.
6. Identify five pieces of information found on a completed charge slip.
7. List four things you will find inside a new patient’s chart.
8. List two reasons to use a checklist.
Psychomotor
9. Open the office.
10. Obtain new patient information.
11. Close the office.
Initial Questions and Activities
 Discuss why it is important to prepare the waiting room and examination areas.
Key Concepts
References & Activities
Slides
Preparing for patients in the office
Pages 183-184
3-4
Procedure 7-1
Receptionist’s duties
Pages 184-185
5-8
Procedure 7-2
Closing the office
Procedure 7-3
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(ICA) In-Class Activities
1. Complete Procedure 7-1.
2. Complete Procedure 7-2; attach the patient information form as the work product
to the performance evaluation checklist.
3. Complete Procedure 7-3.
(ICD) In-Class Discussion
1. What are six recommendations to follow when opening the office?
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(1) unlock the door (2) check the physical environment of the reception area (3) retrieve
phone messages (4) pull the day’s charts (5) check the examination rooms (6) check
common work areas
2. What steps should be taken to close the office at the end of the day?
(1) restock and clean the examination rooms (2) collect the charts unless the physician
needs them for dictations (3) turn off all appliances (4) prepare the bank deposit to take
to the bank (5) activate the answering system (6) turn off the lights (7) lock the door and
activate the alarm system (if there is one).
(HW) Homework Assignments
1. Terminology Notebook. Assign unit for reading and have students define key
terms and retain in a key term notebook for future reference.
2. Chapter 7, Unit 1 Workbook Assignment Sheet.
Presentation Tools
Note to Instructors: If you change Objectives or Assignments, don’t forget to change the
slides accordingly.
Chapter 7,
Slides 1-2
Introduce the course and unit.
Slide 3-4
Opening the office—tasks and things to check.
Slide 5
The importance of the receptionist.
Slide 6
The role of the receptionist.
It may not always be the responsibility of the receptionist to open and
close the office; the office manager may have that duty. This will be
according to each office’s policy and assigned responsibilities.
Slide 7
Charge slips.
Slide 8
New patient charts.
Include what demographics are and why they are important.
Slide 9
Closing the office.
Slide 10
Have students answer the checkpoint questions on the slide to review
the content in the unit.
Part B: The Patient’s Medical Record
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Learning Objectives
Cognitive
1. Define the key terms presented in the unit.
2. Describe the importance of the medical record as a legal document.
3. List examples of subjective information.
4. List examples of objective information.
5. Describe methods of recording progress notes.
6. Describe the correct procedure for making corrections to progress notes.
7. List the differences between a conventional record and the problem-oriented
medical record.
8. Explain the History Physical Impression Plan (HPIP) method of recording
patients’ medical information.
9. Describe the major sections of a medical record.
10. Explain the reason for a tickler file.
11. Explain the purpose of chart audits and their importance.
Initial Questions and Activities
 Talk about the impact of HIPAA for small offices as contrasted to larger medical
settings.
Key Concepts
References & Activities
Slides
HIPAA
Page 190
14-15
Purpose of medical records and what
constitutes a complete medical record
Page 191
12-13, 16-21
Records management
Figure 7-8
28-30
Page 195
POMR
Page 195
Electronic Health Records
Page 198
22-27
(ICA) In-Class Activities
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1. Show a DVD clip—“Administrative and clinical sections of the medical record”
from Program 1: Administrative Skills (Skills and Procedures series).
2. Obtain blank patient charts and inserts and have the students to organize them for
medical records.
3. Provide the student at least one scenario to chart in the SOAP format.
(ICD) In-Class Discussion
1. What is the role of the Privacy Officer that is mandated by HIPAA?
The Privacy Officer tracks who has access to Protected Health Information (PHI) within
each office to ensure patient privacy and confidentiality of the records.
2. What are the rationales behind having a complete medical record?
A complete medical record serves to (1) plan patient care and continuity in the
evaluation of treatment (2) provide documentary evidence of the course of a patient’s
evaluation, treatment, and change in condition (3) furnish evidence of communication
between the physician and any other provider associated with the patient’s care (4)
afford protection of legal interests of the patient and the physician (5) establish a
database for continuing education and research (6) maintain relationship between the
medical office and the insurance company for reimbursement.
(HW) Homework Assignments
1. Terminology Notebook. Assign unit for reading and have students define key
terms and retain in a key term notebook for future reference.
2. Activity. Complete Activity 1 on page 213 of the text.
3. Chapter 7, Unit 2 Workbook Assignment Sheet.
Presentation Tools
Note to Instructors: If you change Objectives or Assignments, don’t forget to change the
slides accordingly.
Chapter 7,
Slide 11
Introduce the unit.
Slides 1213
The medical record as a legal document.
Slides 1415
HIPAA security safeguards.
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Slides 1617
Subjective and objective information found in the medical record.
Slides 1820
Methods of recording progress notes.
Slide 21
Correcting a medical record.
Include in your discussion that errors made in a medical record should
never be scribbled out, obliterated with a marker, or “whited-out.”
Emphasize that documentation in medical records should only be done
in blue or black ink (except for allergies that should be in red ink).
Slide 22
Conventional records versus source-oriented medical records (SOMR)
Slides 2324
The problem-oriented medical record (POMR).
Slides 2526
The SOAP method of charting (subjective, objective, assessment, plan).
Slide 27
The HPIP method of charting (history, physical, impression, plan).
Slide 28
Sections of the medical record.
Subjective information in addition to the chief complaint includes a
history of the present illness (HPI).
Remind the learner that financial information should not be inserted into
the patient medical record.
Slide 29
Tickler files for managing medical records.
Slide 30
Chart audits.
Identify who is responsible for performing chart audits.
Slide 31
Have students answer the checkpoint questions on the slide to review
the content in the unit.
Part C: Filing
Learning Objectives
Cognitive
1. Define the key terms presented in the unit.
2. Explain basic filing methods.
3. List the steps used in filing.
4. Describe methods of removing and replacing patient files.
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5. List the storage media used for “paperless” filing systems.
6. List and discuss the sections of a medical chart.
7. Describe purging files.
8. Explain ways to locate a missing chart.
9. Explain the pros and cons of alphabetical and numeric filing systems.
Psychomotor
10. File items alphabetically.
11. Pull a file folder from alphabetic files.
12. File items numerically.
13. Pull a file folder from numeric files.
Key Concepts
References & Activities
Slides
Filing steps
Figure 7-12
33-35
Pages 200-201
File management: finding a missing chart,
storage, and supplies
Pages 201-205
36, 37, 40
Rules of alphabetical filing
Pages 206-208
41
Procedure 7-4
Procedure 7-5
Rules of numeric filing
Pages 208-209
42
Procedure 7-6
Procedure 7-7
When and how to purge files
Pages 211-212
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(ICA) In-Class Activities
1. Prior to completing Procedure 7-4, give the student at least ten words to place in
alphabetical order as practice.
2. Complete Procedure 7-4.
3. Complete Procedure 7-5.
4. Complete Procedure 7-6.
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5. Complete Procedure 7-7.
6. Following review of the chapter and homework assignments, give a quiz on this
chapter that includes the content and competencies listed for CAAHEP and
ABHES.
(ICD) In-Class Discussion
1. Name the five steps for proper filing technique.
(1) inspect (2) index (3) code (4) sort (5) store
2. Which filing system is the most effective in protecting patient privacy?
The numerical filing system serves to protect the patient’s privacy as the chart (medical
record) does not reference the patient name on its exterior.
3. True or False? If a patient has not seen the physician for two or more years, it is
acceptable practice to dispose of the record.
False; the patient may return. If the patient is deceased, forms may be requested for
completion.
(HW) Homework Assignments
1. Terminology Notebook. Assign unit for reading and have students define key
terms and retain in a key term notebook for future reference.
2. Have the student to research the state law for the length of time medical records
must be retained for your state.
3. Chapter 7, Unit 3 Workbook Assignment Sheet.
4. The Critical Thinking Challenge, page 212.
5. The StudyWare Challenge, Chapter 6. Have students take the Quiz in “Quiz
Mode” and either email their scores to the instructor, or print the scores to turn in.
Presentation Tools
Note to Instructors: If you change Objectives or Assignments, don’t forget to change the
slides accordingly.
Chapter 7,
Slide 32
Introduce the unit.
Slide 33
Basic filing methods.
Click on the icon to play a brief video clip.
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Slides 3435
Steps in filing.
Slide 36
Removing and replacing medical records—using OUTguides.
Slide 37
Paperless filing systems.
Slide 38
Sections of a medical chart.
Slide 39
Purging files.
Slide 40
Locating missing charts.
Slide 41
Alphabetic filing system.
Slide 42
Numeric filing system.
Slide 43
Have students answer the checkpoint questions on the slide to review
the content in the unit.
Slides 4445
The Keys to Career Success slides emphasize the relationship of the
material learned in the classroom to on-the-job success.
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