Medical Record Keeping Course
Example Patient Medical Records are Required!
For completion of the Medical Record Keeping course, two medical record workshops with analysis of patient records submitted by the attendee are REQUIRED.
- Select a day at random and collect the medical records of the first 4 patients you saw in your office or clinic that day.
- For each of the four patients, photocopy only the page(s) of your medical record containing the record entry for that one visit.
- Find all patient-identifiable information on those photocopies, including patient names, family member names, numbers, location, and any other information on the pages that could be used to identify the patient. Block out all the patient-identifiable information with a heavy black marker so that all patient-identifiable information is completely unreadable.
- Find and block out all of the following that are in the patient’s records:
a. Your name.
b. The name of your facility and its location.
c. The names and locations of any other clinicians or facilities mentioned in the patient’s records.
- Include a cover letter with your name so we know who submitted the patient records.
- Mail the photocopies no less than 2 weeks prior to the start of the Record Keeping course to:
Western Institute of Legal Medicine
1700 South El Camino Real, Suite 408
San Mateo, CA 94402
If the mailed photocopies are not actually received by the Western Institute of Legal Medicine no less than 5 days prior to the start of the course, credit acceptable to the Medical Board of California cannot be given for completion of the Record Keeping course.