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Medical Record Documentation for Correctional Health Care Professionals

Designed to orient new health care employees and to provide ongoing annual review, this four-hour training curriculum discusses the importance of maintaining complete medical records on patients/inmates. Performance objectives include: discussing purposes and uses of medical records; describing the components of the problem oriented medical record; demonstrating proper charting techniques; and describing methods used in the maintenance of medical records for correctional facilities. The curriculum model contains "Lecture Notes" and text for overheads for the trainer, as well as "Lecture Guides" for the trainee, on the following units: Introduction, Overview, Technical Documentation, Confidentiality, and Transfer of Information. Accession Number: 009715

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