21st Century Instructional Guide for Career Technical Education
Medical Filing and Applications
Health Science Education Cluster
Medical Transcription and Information Specialist Concentration
Title:
Medical Filing and Applications (0726)
Standard
Number:
HSE.S.MFA.1
Essential
Questions:
Medical Filing
Students will demonstrate knowledge and skills in filing and retrieving medical records using numeric
filing, alphabetic filing, cross-referencing, color coding, records control and computer-assisted filing.
Some physicians and medical institutions keep medical records in perpetuity, while others destroy
medical records after storing them for the amount of time mandated by the federal and state
regulations. Which is best and why?
Students will
Learning Plan & Notes to Instructor:
examine the purpose of medical filing.
medical record content
 identifying data
 family history
 patient history
 physical findings
 testing
 diagnosis
 last name, first name, middle initial, treatment
purpose of filing
differentiate the five phases of the medical
five phases
record’s life cycle, giving examples of each
 creation
phase.
 use
 storage
 retrieval
 disposition
Note: use WVMA handout; result of breach of
determine the purpose of confidentiality,
confidentiality: fine and/or imprisonment.
identifying the control of information
released.
distinguish two methods of storing medical
methods
records.
 alphabetical
Objectives:
HSE.O.MFA.1.1
HSE.O.MFA.1.2
HSE.O.MFA.1.3
HSE.O.MFA.1.4
1
HSE.O.MFA.1.5
compare cross-referencing methods.
HSE.O.MFA.1.6
examine the master patient index.
HSE.O.MFA.1.7
differentiate the three most common pieces
of storage equipment used for medical filing.
HSE.O.MFA.1.8
determine filing supplies used for medical
filing.
HSE.O.MFA.1.9
assess alternative storage methods for
patient health records.
HSE.O.MFA.1.10
report the necessity for indexing rules in
alphabetic storage of names.
HSE.O.MFA.1.11
examine the importance of consistently
following indexing rules.
index and arrange names (i.e. indexing order
units, with punctuation and possessives,
abbreviations, nicknames, and shortened
names, prefixes, foreign articles and
particles, titles and suffixes, names that are
identical, and names for phonetic filing
system).
HSE.O.MFA.1.12
 mathematical
cross-referencing methods
 alphabetical
 mathematical
Note: Is a master patient index alphabetical or
numeric?
storage equipment
 lateral cabinets
 vertical cabinets
 shelving files
filing supplies
 color coding methods
 allergy and medical directive information
 numeric/alphabetic filing preferences.
alternative storage methods
 microfilming
 optical disk storage
Note: indexing rules help retrieve information
efficiently.
Note: consistently following established indexing
rules helps keep misfiles at a minimum.
index rules
 last name, first name, middle name.
 disregard all punctuation.
 abbreviations and nicknames indexed as
written.
 disregard space between foreign article in
person’s name.
 titles and suffixes are the last indexing unit.
 royal and religious titles followed by a given
name are the first indexing unit.
 Identical names filing order is determined by
addresses (considering cities first).
 sound alike/spelled differently are filed
2
HSE.O.MFA.1.13
HSE.O.MFA.1.14
HSE.O.MFA.1.15
HSE.O.MFA.1.16
HSE.O.MFA.1.17
HSE.O.MFA.1.18
HSE.O.MFA.1.19
HSE.O.MFA.1.20
HSE.O.MFA.1.21
HSE.O.MFA.1.22
HSE.O.MFA.1.23
together.
Note:
numeric
systems are used when number of
differentiate between serial, unit, serial-unit,
files are vast.
and social security numbering system.
differentiate between storing records by
storage of records
consecutive numeric, terminal-digit, and
 consecutive systems
middle-digit filing methods.
 nonconsecutive systems
demonstrate filing numeric cards in
filing
consecutive, terminal-digit, and middle-digit
 consecutive is straight
order.
 numeric terminal is divided into groups, read
from right to left
 middle-digit grouped in pairs and primary is
the two middle digits.
recognize the purpose of cross-referencing.
purpose of cross-referencing
 used when a name might be indexed in more
than one way
recognize four types of personal names that
personal names requiring cross-referencing
require cross-referencing and give an
 unusual
example of each.
 alternate
 hyphenated
 similar
Student Learning Activity: complete assignments in
apply cross-referencing in numeric filing.
workbook.
assess the purpose of color coding for
purpose of color coding
medical records filing.
 retrieve medical records quickly
 reduce misfiles
distinguish the two numeric filing systems
color coding
that are best suited for color coding.
 terminal
 middle-digit filing
differentiate two areas other than alphabetic
color coding
and numeric filing where color coding may be
 indicates file activity
utilized.
 imparts personal information
examine numeric color coding.
numeric color coding
 combinations of letters for color patterns
recognize misfiles in color-coded medical
recognition of misfiles
files.
 break in the color pattern within the files.
3
HSE.O.MFA.1.24
HSE.O.MFA.1.25
HSE.O.MFA.1.26
HSE.O.MFA.1.27
HSE.O.MFA.1.28
HSE.O.MFA.1.29
HSE.O.MFA.1.30
HSE.O.MFA.1.31
HSE.O.MFA.1.37
HSE.O.MFA.1.38
Standard
determine the purpose of charge-out
procedures when a medical record is
borrowed.
recognize advantages of an automated
tracking system.
differentiate between active and inactive
medical records, indicating how each is
determined.
establish the recommended time period
medical records should be retained.
charge out procedures
 used for tracking purposes
Note: describe a tickler file to students.
differentiate active and inactive records
 assign each year a different color, can spot
inactive files this way
retention of records
 federal law – 5 years
 state law varies
compare appropriate methods for destruction destruction of files
of medical records.
 determine if active or inactive
 observe federal/state mandated retention
periods
 shred or burn files
examine three types of computer
types of computer applications
applications for medical facilities.
 administrative
 financial
 clinical
assess three types of administrative
administrative databases
databases used in medical facilities.
 appointment scheduling
 patient registration
 location and tracking
articulate four types of financial databases
financial databases
used in medical facilities.
 billing
 patient ledger
 daily charges
 claims processing
examine clinical computer applications.
clinical computer applications
 diagnosis and treatment information
research mechanisms for maintaining
maintaining security
security and confidentiality of computerized
 passwords
health information.
 encryption
Medicolegal Aspects of the Healthcare Record
4
Number:
HSE.S.MFA.2
Essential
Questions:
Objectives:
HSE.O.MFA.2.1
HSE.O.MFA.2.2
HSE.O.MFA.2.3
HSE.O.MFA.2.4
HSE.O.MFA.2.5
HSE.O.MFA.2.6
HSE.O.MFA.2.7
HSE.O.MFA.2.8
HSE.O.MFA.2.9
HSE.O.MFA.2.10
HSE.O.MFA.2.11
Students will:
 demonstrate knowledge of the healthcare record, including the voluntary and regulatory
standards related to the healthcare record and medical transcription.
 apply medicolegal concepts and ethics in the medical transcription profession.
Insurance companies can sell customer’s diagnostic medical information to pharmaceutical
companies, etc., while physicians and medical institutions are held to higher standards of patient
confidentiality. Should this be allowed?
Students will
Learning Plan & Notes to Instructor:
Note: Confidentiality and Compliance handout
determine the characteristics and use of the
healthcare record as a legal document.
Note: use AAMT Book of Style for reference.
differentiate formats of commonly dictated
reports, utilizing each.
differentiate required content of the
required content
healthcare document and its components.
 most recent information on top, in order down
to first patient encounter
Note: “Golden Rule: If it is not documented, it did
analyze the relationship of medical
not happen.”
transcription to the healthcare record.
Note: “If it is not signed, it is not documented.”
examine legal, regulatory, and standards
requirements for authentication of healthcare
documents.
determine the meaning of basic medicolegal Note: date dictated, date transcribed, initials of
dictator, initials of transcriptions
terminology as it pertains to medical
transcription.
contrast voluntary and regulatory standards
contrast
related to the healthcare record and medical
 JCAHO
transcription.
 Medicare
Suggestion: “discuss JCAHO visits to area hospitals
examine the influence of voluntary and
and the fact that it is a voluntary investigation.
regulatory agencies on standard setting for
JCAHO is the “tail” that wags the Medicare “dog”.”
healthcare documentation.
Student Learning Activity: conduct Internet research
assess general concepts of medical and
of medical and professional ethics.
professional ethics.
examine and comply with the AAMT Code of AAMT Code of Ethics
Student Learning Activity: conduct Internet search
Ethics.
and use for discussion with students.
recognize risk management implications
risk management implications
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within transcribed documents, reporting
them appropriately.
HSE.O.MFA.2.12
HSE.O.MFA.2.13
HSE.O.MFA.2.14
examine patient rights to privacy,
confidentiality, and release of patient
information, including but not limited to
HIPAA.
implement into practice patient rights of
privacy, confidentiality, and release of patient
information, including but not limited to
HIPAA.
recognize potential liability issues for medical
transcriptionists.

malapropisms, slips of tongue, slang,
right/left discrepancy,
derogatory/inflammatory remarks concerning
patients and personnel, etc.
Student Learning Activity: conduct Internet research
on HIPAA guidelines.
Note: always use appropriate chain of command
(immediate supervisor) when reporting questionable
dictation containing potential breeches of privacy
rights and confidentiality rules/laws.
potential liability issues
 breach of confidentiality
 changing documentation information and
dates to protect self or others
continuing education resources
 AHDI
 AHIMA
references
 AHDI Code of Ethics
 HIPAA Guidelines
 AMA
HSE.O.MFA.2.15
recognize resources for continuing education
in healthcare documentation.
HSE.O.MFA.2.16
use appropriate references and resources as
necessary.
Standard
Number:
HSE.S.MFA.3
Professional Development
Students will:
 develop professional work behaviors.
 demonstrate knowledge in the dynamics of the work environment.
 demonstrate an awareness of professional development and career opportunities.
If you were an independent contractor running your own medical records storage business, what
actions would you take regarding release of records belonging to patients whose physician has not
paid his storage fee to your company?
Students
Learning Plan & Notes to Instructor:
Studentswill
will
Note: place student in temporary clinical; provide
demonstrate effective interpersonal
feedback based on observations of office manager.
communication and teamwork skills in
problem solving and/or conflict management.
Essential
Questions:
Objectives:
HSE.O.MFA.3.1
6
HSE.O.MFA.3.2
assess time management techniques,
implementing techniques into practice.
HSE.O.MFA.3.3
examine stress management techniques.
HSE.O.MFA.3.4
determine the importance of flexibility and
adaptability in the workplace.
examine components of a professional
image.
demonstrate attributes of professionalism
within practice.
HSE.O.MFA.3.5
HSE.O.MFA.3.6
HSE.O.MFA.3.7
distinguish career opportunities in the
medical transcription industry.
HSE.O.MFA.3.8
prepare a resume.
HSE.O.MFA.3.9
complete an employment application.
HSE.O.MFA.3.10
participate in a mock job interview.
HSE.O.MFA.3.11
prioritize work-related obligations.
HSE.O.MFA.3.12
assess the importance of ethical conduct in
the workplace.
time management techniques
 explore flex scheduling
 productivity pay
 ergonomics
stress relieving exercises
 stretching
Note: “hospitals operate 24/7”
Suggestion: guest speaker from area hospital’s
Human Resources Director
Student Learning Activity: following student
practicum students are to write a report containing
observations of conduct of office personnel worthy of
modeling
career opportunities for transcriptionists
 medical centers
 general and specialty hospitals
 clinics and group practices
 radiology and pathology offices
 government facilities
 insurance companies
 home offices
Student Learning Activity: have students use
Microsoft word resume templates to create resume.
Student Learning Activity: complete online
employment applications for area hospitals.
Suggestion: conduct mock interviews; invite office
manager from local medical office as guest speaker.
work-related obligations
Suggestion: “discuss ‘first in, first out’ and priority
dictation”.
ethics
 breech of confidentiality will result in loss of
job, criminal charges and possible fine or
imprisonment
7
HSE.O.MFA.3.13
HSE.O.MFA.3.14
HSE.O.MFA.3.15
HSE.O.MFA.3.16
HSE.O.MFA.3.17
differentiate between the characteristics of
various work settings (i.e. hospital, service,
and home- based offices).
differentiate features/characteristics of
different work environments (i.e.
compensation, benefits, schedules).
demonstrate skills in negotiating terms of
employment.
utilize techniques for measurement of
outcomes (i.e.quality, turn-around time,
productivity).
compare employee and employer rights.
Discuss national companies versus local venues.
"stress need for ability to stay on task, be detail
oriented, self-governing.”
Suggestion: guest speaker from CAMC Human
Resource Department or other area industry HRD.
Student Learning Activity: conduct mock interviews.
techniques for measurement of outcomes
 TAT: one minute dictation = three minutes
transcribing, normally and with experience.
See US Dept. of Labor Employee and Employer
Rights.
value of professional organizations
 affiliation helps one stay abreast of latest
industry standards and practices
AAMT certification
 students are eligible to take RMT examination
upon course completion.
 continue to participate as a member of AHDI
after obtaining a job
 must work in a multi-specialty setting for a
minimum of two years prior to taking AHDI
CMT examination
HSE.O.MFA.3.18
determine the value of affiliating with
professional organizations such as AAMT.
HSE.O.MFA.3.19
develop plans to attain AAMT professional
certification.
Standard
Number:
HSE.S.MFA.4
Essential
Questions:
Objectives:
HSE.O.MFA.4.1
Entrepreneurship
Students will develop basic knowledge and skills in entrepreneurship within health information
management.
How has the application of information technology impacted healthcare careers?
Students will
illustrate the basic differences among
employee, statutory employee, and
independent contractor status including the
potential tax, insurance, and liability
implications of each.
Learning Plan & Notes to Instructor:
8
HSE.O.MFA.4.2
HSE.O.MFA.4.3
HSE.O.MFA.4.4
HSE.O.MFA.4.5
HSE.O.MFA.4.6
HSE.O.MFA.4.7
HSE.O.MFA.4.8
HSE.O.MFA.4.9
HSE.O.MFA.4.10
Standard
Number:
HSE.S.MFA.5
Essential
Questions:
Objectives:
HSE.O.MFA.5.1
HSE.O.MFA.5.2
Standard
Number:
examine the meaning and implications of
entrepreneurship.
characterize basic business management
practices.
relate procedures and requirements for
practicing as an independent contractor (i.e.
business licensing, contracts, taxes, space,
equipment, pricing).
determine a list of equipment that will meet
the needs of the workplace.
recognize basic equipment contract and
warranty terms, conditions, and the need for
maintenance and service agreements.
examine common ergonomic problems and
solutions in the medical transcription work
environment.
demonstrate networking skills such as
attending meetings of AAMT component
associations.
construct a plan to implement successful
continuing education.
use appropriate references and resources for
research and practice.
Information Technology Applications
Students will
 use information technology applications required within all career specialties.
 demonstrate use as appropriate to healthcare applications.
How has the application of information technology impacted healthcare careers?
Students will
Learning Plan & Notes to Instructor:
implement the use of software and hardware. Use software, hardware, and Internet throughout
delivery of CSOs.
Use Internet for resource/research for projects and
utilize the Internet as a resource/research
assignments.
tool.
Career and Technical Student Organization
Students will participate in the local chapter of the Career and Technical Student Organization
9
HSE.S.MFA.6
Essential
Questions:
Objectives:
HSE.O.MFA.6.1
HSE.O.MFA.6.2
HSE.O.MFA.6.3
HSE.O.MFA.6.4
21st Century
Skills
Information and
Communication
Skills:
(CTSO).
How does participation in a Career and Technical Student Organization (CTSO) impact professional
development and lifelong learning?
Students will
Learning Plan & Notes to Instructor:
See www.HOSA.org.
participate in the local chapter of the
appropriate Career and Technical Student
Organization (CTSO).
See Robert’s Rules of Order.
use parliamentary procedures in chapter
meetings.
See HOSA Handbook.
demonstrate team membership/leadership
and
problem solving skills.
See HOSA Handbook.
participate in local, state, and national
projects
impacting healthcare and healthcare
education.
Learning Skills & Technology Tools
Teaching Strategies
Evidence of
Culminating Activity
Success
21C.O.9Student recognizes
Students use search engines Students complete
12.1.LS1.
information needed for
to complete an online search workbook exercises
problem solving, can
for pertinent medical filing
correctly, in a timely
efficiently browse, search
information.
fashion.
and navigate online to
access relevant information, Students prepare an oral
Reports must meet
evaluates information based report, which may include
specific criteria
on credibility, social,
power point presentations,
concerning
economic, political and/or
upon return from their clinical grammar, timeliness,
ethical issues, and presents site placement.
length, and content.
findings clearly and
persuasively using a range
of technology tools and
media.
21C.O.9Student uses audio, video,
12.1.TT4
pictures, clip art,
moviemaker programs,
webpage design software,
10
Thinking and
Reasoning Skills:
21C.O.912.2.LS1
21C.O.912.2.TT2
21C.O.912.3.TT3
Personal and
Workplace Skills:
21C.O.912.3.LS1
electronic documents and
other files to collaborate for
the creation of electronic
products that inform multiple
audiences both inside and
outside the school
environment.
Student engages in a critical
thinking process that
supports synthesis and
conducts evaluation using
complex criteria.
Student collaborates with
peers, experts and others to
contribute to a contentrelated knowledge base by
using technology to
compile, synthesize,
produce, and disseminate
information, models, and
other creative works.
Student evaluates current
trends in information
technology, discusses the
potential social, ethical,
political, and economic
impact of these
technologies, and analyzes
the advantages and
disadvantages of
widespread use and
reliance on technology in
the workplace and society.
Student remains composed
and focused, even under
stress, willingly aligns
Students create electronic
files within a medical filing
tutorial loaded on laboratory
computers, entering both
demographic and medical
information.
Students work within
Medical Manager
Tutorial software
program to create
patient medical files.
Students actively participate
in classroom discussion and
attend lectures concerning
confidentiality and compliance
issues related to medical
filing.
Students conduct
themselves
satisfactorily while in
a medical filing
clinical situation.
Students are assigned a
Student receives
medical filing clinical where
satisfactory report
he/she learns to communicate from medical filing
11
his/her personal goals to the
goals of others when
appropriate, approaches
conflict from win-win
perspective, and derives
personal satisfaction from
achieving group goals.
21C.09Student protects software,
12.3.TT1
hardware and network
resources from viruses,
vandalism, and
unauthorized use and
employs proper techniques
to access, use and shut
down technology
equipment.
Learning Skills & Technology Tools
Entrepreneurship
Skills:
B.01-.06;.08;
11
D.06-.07; .11;
.16; .17; .22.26
E.01; .07; .13
Culminating
Assessment:
Understands the personal
traits/behaviors associated
with successful
entrepreneurial
performance.
Understands concepts,
strategies, and systems
needed to interact
effectively with others.
Understands concepts and
procedures needed for
basic computer operations.
effectively and work as a
member of an established
office team.
clinical supervisor.
Students are cautious with
laboratory equipment, both
hard ware and soft ware, and
routinely and automatically
return reference materials,
CDs, and tapes to proper
storage areas.
Students leave
laboratory and
classroom areas
only after having
replaced equipment,
etc., to appropriate
storage areas
without having to be
instructed to do so.
Evidence of
Success
Students receive a
positive evaluation
from clinical site
supervisor.
Teaching Strategies
Culminating Activity
Students are placed in a
medical filing clinical site and
learn to work as a team, to
address/assist clients
regarding medical records
information.
Students participate in
creation, maintenance, and
filing of medical records.
Culminating Assessment
Scenario: You are working in a clinic. The practice sees approximately 100 patients per day. Given
75 charts, index and arrange names (i.e. indexing order units, with punctuation and possessives,
abbreviations, nicknames, and shortened names, prefixes, foreign articles and particles, titles and
suffixes, names that are identical, and names for phonetic filing system) for file storage. Each of
12
the patients will also have a numeric card, file the cards (25 cards in each order) in consecutive,
terminal-digit, and middle-digit order.
Final Examination
Industry
Accreditation/
Certification
Industry Accreditation/Certification
No certification available at the completion of this course.
Links and Other Resources
Links and Other
Resources:
Related Websites:
Association for Healthcare Documentation Integrity
www.ahdionline.org
Pathways to Success
http://careertech.k12.wv.us/pathwaystosuccess/
U.S. Department of Labor in the 21st Century
http://www.dol.gov/
Advanced Distributed Learning
www.adlnet.org
America's Career InfoNet
www.acinet.org
America's Job Bank
www.ajb.org
America's Service Locator
www.servicelocator.org
CareerOneStop
www.careeronestop.org
Employment & Training Administration
13
www.doleta.gov
The Job Accommodation Network (JAN)
http://www.jan.wvu.edu
Monthly Labor Review Online: Labor Force Archives
http://www.bls.gov/opub/mlr/indexL.htm#Labor force
Occupational Information Network
www.doleta.gov/programs/onet
Office of Disability Employment Policy
www.dol.gov/odep
Career Voyages
http://www.careervoyages.gov/index.cfm
Workforce West Virginia
https://www.workforcewv.org/
West Virginia Earn A Degree Graduate Early (EDGE)
http://www.wvtechprep.wvnet.edu/edge.htm
West Virginia Career and Technical Education
http://careertech.k12.wv.us/
Contacts:
Contacts
HSE Teachers: See HSE Directory
HSE Coordinators: Rebecca Davis rdavis@access.12.wv.us
Cynthia Sundstrom csundstr@access.k12.wv.us
OCTI Assistant Executive Director and EOCTST Coordinator: Donna Burge-Tetrick
OCTI Executive Director: Gene Coulson
14