Course Description
| Course | Code | Semester | T+P (Hour) | Credit | ECTS |
|---|---|---|---|---|---|
| MEDICAL DOCUMENTATION | HM2166680 | Fall Semester | 2+0 | 2 | 3 |
| Course Program |
| Prerequisites Courses | |
| Recommended Elective Courses |
| Language of Course | English |
| Course Level | First Cycle (Bachelor's Degree) |
| Course Type | Elective |
| Course Coordinator | Prof.Dr. Yeter USLU |
| Name of Lecturer(s) | Assist.Prof. Aliye Aslı SONSUZ |
| Assistant(s) | Resarch Assistant Yaşar GÖKALP |
| Aim | To teach how to establish an archive for medical documents and show how to provide these documents to users. |
| Course Content | This course contains; 1. Patient Relations Management I,2. Patient Relations Management II,3. Basic definitions related to medical records, definitions of document and medical documentation, importance and value of medical documentation.,4. Historical background of medical records, use, analysis and development of medical records.,5. Tasks, qualifications and importance of medical secretaryship,6. Data, information and information system,7. Main components of patient file archieves in health institutions,8. Organization, functions, budget and committee of archieve,9. Numeration, putting in order and file of patient records,10. Indexes for patient files, physians, diseases and operations, sytems for indexes,11. Jurisprudence side of patient files, information demands of official authorities, contracted institutions, patients and patient's relatives,12. Computer usage in patient file archieves,13. Prefixes, stems and suffixes of medical terms,14. International classification of diseases and medical interventions. |
| Dersin Öğrenme Kazanımları | Teaching Methods | Assessment Methods |
| At the end of this course, the student; | ||
| 1. Perceive basic definitions and concepts related to medical documents. | 16, 9 | A |
| 2. Evaluate the historical development of medical documents and assesses their importance. | 16, 9 | A |
| 3. Discuss privacy, protection and standardization of medical documents. | 16, 9 | A |
| 4. Recognize the legal legislation related to medical documentation in health institutions. | 9 | E |
| 5. Arrange patient files. | 9 | A |
| 6. Arrange patient files. | 9 | A |
| 7. Establish the archive system. | 9 | A |
| 8. Establish index for patient files. | 9 | A |
| 9. Compare international classification systems related to disease. | 9 | A |
| 10. Compare health informatics and hospital information systems. | 16, 9 | |
| 11. Extract medical documentation from electronic resources and databases. | 9 | A |
| 12. Prepare documentation system in the framework of quality management tasks. | 9 | A |
| 13. Design documents that will be used in quality management works. | 9 | E |
| Teaching Methods: | 16: Question - Answer Technique, 9: Lecture Method |
| Assessment Methods: | A: Traditional Written Exam, E: Homework |
Course Outline
| Order | Subjects | Preliminary Work |
|---|---|---|
| 1 | 1. Patient Relations Management I | Review the related resources |
| 2 | 2. Patient Relations Management II | Review the related resources |
| 3 | 3. Basic definitions related to medical records, definitions of document and medical documentation, importance and value of medical documentation. | Review the related resources |
| 4 | 4. Historical background of medical records, use, analysis and development of medical records. | Review the related resources |
| 5 | 5. Tasks, qualifications and importance of medical secretaryship | Review the related resources |
| 6 | 6. Data, information and information system | Review the related resources |
| 7 | 7. Main components of patient file archieves in health institutions | Review the related resources |
| 8 | 8. Organization, functions, budget and committee of archieve | Review the related resources |
| 9 | 9. Numeration, putting in order and file of patient records | Review the related resources |
| 10 | 10. Indexes for patient files, physians, diseases and operations, sytems for indexes | Review the related resources |
| 11 | 11. Jurisprudence side of patient files, information demands of official authorities, contracted institutions, patients and patient's relatives | Review the related resources |
| 12 | 12. Computer usage in patient file archieves | Review the related resources |
| 13 | 13. Prefixes, stems and suffixes of medical terms | Review the related resources |
| 14 | 14. International classification of diseases and medical interventions | Review the related resources |
| Resources |
| Lecture Notes |
| Uçmaz R. Tıbbi Dokümantasyon 1, Uludağ Üniversitesi Meslek Yüksekokulu Yayınları, Bursa, 2004. Uçmaz R. Tıbbi Dokümantasyon 2, Uludağ Üniversitesi Meslek Yüksekokulu Yayınları, 2004. Göçmen E., Tıbbi Kayıtların Tutulması ve Hukuki Sorumluluk, http://www.hastaninhaklari.com/tibbikayitlarintutulmasi.htm Yılmaz A., Kaplan A., Sincan M., Elektronik Hasta Kayıt Sistemine Kavramsal Bir Yaklaşım http://www.sabem.saglik.gov.tr/Akademik_Metinler/goto.aspx?id=2440 Di Lima S.N., Johns T.L. "Health Information Management" AspenPublication, Maryland, 1998. ICD10.CM International Classification of Disseases 10 TH Revision, Tıbbi Terminoloji, Prof.Dr.Adil Artukoğlu Tıbbi Dokümantasyon, Prof.Dr.Adil Artukoğlu, Arşiv Binaları ve techizatı, MichealDuchein, Çeviren : Cemil Göker Kadir Sümbüloğlu, Vildan Sümbüloğlu, Tıbbi Dokümantasyon, Somgür Yayıncılık, Ankara |
Course Contribution to Program Qualifications
| Course Contribution to Program Qualifications | |||||||
| No | Program Qualification | Contribution Level | |||||
| 1 | 2 | 3 | 4 | 5 | |||
| 1 | PQ-1. Learns the national health conditions and the development, implementation and performance evaluation of appropriate health policies, as well as the theoretical and practical knowledge of organization and management of the health sector. | X | |||||
| 2 | PQ-2. Knows and uses theoretical and practical knowledge on business world and management with a critical approach to plan, organize and lead health and health service providers at national and international level. | X | |||||
| 3 | PQ-3. Identifies the relevant job roles in subdivisions of health system organizations and learns about their duties and responsibilities. | X | |||||
| 4 | PQ-4. Knows the social, environmental and behavioral factors related to the development of public and individual health. | X | |||||
| 5 | PQ-5. Applies the knowledge and skills on management of health institutions to manage the functions such as management, production, human resources, finance, accounting, marketing, patient and public relations, quality and patient safety, occupational health and safety, information technologies. | X | |||||
| 6 | PQ-6. Analyzes the information on health management scientifically and interprets their results, creates innovative, ethical, socially responsible and sustainable solutions, by using quantitative, qualitative techniques and digital technology innovatively for problem solving and exploiting opportunities in health management. | X | |||||
| 7 | PQ-7. Decide independently and demonstrates leadership qualities in identifying health management problems, develops proposals for solutions, applies them effectively and efficiently and assesses outcomes. | X | |||||
| 8 | PQ-8. Takes responsibility as an individual and/or team member to solve the problems encountered in managing health institutions. | X | |||||
| 9 | PQ-9. Evaluates the personality, culture and behavioral characteristics of the health institutions’ employees and directs them towards the aims of the institution. | X | |||||
| 10 | PQ-10. Decides on and applies different ways of accessing information. | X | |||||
| 11 | PQ-11. Continuously develops their professional knowledge and skills; be open to change, innovation, entrepreneurship and lifelong learning. | X | |||||
| 12 | PQ-12. Shares the views and suggestions on health management issues in writing and orally with stakeholders and communicates effectively with colleagues using an English level of at least European Language Portfolio B1 General. | ||||||
| 13 | PQ-13. Solves problems using effective communication methods, has the ability to use the language in written and oral communication in a correct and proper manner using the terminology of health institutions. | X | |||||
| 14 | PQ-14. Uses information and communication technologies and computer software at least at the European Computer Use License level. | ||||||
| 15 | PQ-15. Yönetim felsefesini ve yönetimin fonksiyonlarını her bir birime uygun olacak biçimde yönetim uygulamalarına yansıtır. | X | |||||
| 16 | PQ-16. Birey olarak dış görünüm olumlu tutum ve davranışlarıyla kuruma örnek olur; sürekli gelişme ve değişime açıktır. | X | |||||
| 17 | PQ-17. Sağlık yönetimi ile ilgili hukuki düzenlemeler ile toplumsal, bilimsel, mesleki etik ilkelere uygun, ülke ya da dünya genelinde genel sağlık sorunlarına duyarlı davranır, çözüm önerilerini yorumlar ve değerlendirir. | X | |||||
Assessment Methods
| Contribution Level | Absolute Evaluation | |
| Rate of Midterm Exam to Success | 40 | |
| Rate of Final Exam to Success | 60 | |
| Total | 100 | |
| ECTS / Workload Table | ||||||
| Activities | Number of | Duration(Hour) | Total Workload(Hour) | |||
| Course Hours | 14 | 2 | 28 | |||
| Guided Problem Solving | 2 | 6 | 12 | |||
| Resolution of Homework Problems and Submission as a Report | 1 | 10 | 10 | |||
| Term Project | 0 | 0 | 0 | |||
| Presentation of Project / Seminar | 0 | 0 | 0 | |||
| Quiz | 0 | 0 | 0 | |||
| Midterm Exam | 1 | 15 | 15 | |||
| General Exam | 1 | 25 | 25 | |||
| Performance Task, Maintenance Plan | 0 | 0 | 0 | |||
| Total Workload(Hour) | 90 | |||||
| Dersin AKTS Kredisi = Toplam İş Yükü (Saat)/30*=(90/30) | 3 | |||||
| ECTS of the course: 30 hours of work is counted as 1 ECTS credit. | ||||||
Detail Informations of the Course
Course Description
| Course | Code | Semester | T+P (Hour) | Credit | ECTS |
|---|---|---|---|---|---|
| MEDICAL DOCUMENTATION | HM2166680 | Fall Semester | 2+0 | 2 | 3 |
| Course Program |
| Prerequisites Courses | |
| Recommended Elective Courses |
| Language of Course | English |
| Course Level | First Cycle (Bachelor's Degree) |
| Course Type | Elective |
| Course Coordinator | Prof.Dr. Yeter USLU |
| Name of Lecturer(s) | Assist.Prof. Aliye Aslı SONSUZ |
| Assistant(s) | Resarch Assistant Yaşar GÖKALP |
| Aim | To teach how to establish an archive for medical documents and show how to provide these documents to users. |
| Course Content | This course contains; 1. Patient Relations Management I,2. Patient Relations Management II,3. Basic definitions related to medical records, definitions of document and medical documentation, importance and value of medical documentation.,4. Historical background of medical records, use, analysis and development of medical records.,5. Tasks, qualifications and importance of medical secretaryship,6. Data, information and information system,7. Main components of patient file archieves in health institutions,8. Organization, functions, budget and committee of archieve,9. Numeration, putting in order and file of patient records,10. Indexes for patient files, physians, diseases and operations, sytems for indexes,11. Jurisprudence side of patient files, information demands of official authorities, contracted institutions, patients and patient's relatives,12. Computer usage in patient file archieves,13. Prefixes, stems and suffixes of medical terms,14. International classification of diseases and medical interventions. |
| Dersin Öğrenme Kazanımları | Teaching Methods | Assessment Methods |
| At the end of this course, the student; | ||
| 1. Perceive basic definitions and concepts related to medical documents. | 16, 9 | A |
| 2. Evaluate the historical development of medical documents and assesses their importance. | 16, 9 | A |
| 3. Discuss privacy, protection and standardization of medical documents. | 16, 9 | A |
| 4. Recognize the legal legislation related to medical documentation in health institutions. | 9 | E |
| 5. Arrange patient files. | 9 | A |
| 6. Arrange patient files. | 9 | A |
| 7. Establish the archive system. | 9 | A |
| 8. Establish index for patient files. | 9 | A |
| 9. Compare international classification systems related to disease. | 9 | A |
| 10. Compare health informatics and hospital information systems. | 16, 9 | |
| 11. Extract medical documentation from electronic resources and databases. | 9 | A |
| 12. Prepare documentation system in the framework of quality management tasks. | 9 | A |
| 13. Design documents that will be used in quality management works. | 9 | E |
| Teaching Methods: | 16: Question - Answer Technique, 9: Lecture Method |
| Assessment Methods: | A: Traditional Written Exam, E: Homework |
Course Outline
| Order | Subjects | Preliminary Work |
|---|---|---|
| 1 | 1. Patient Relations Management I | Review the related resources |
| 2 | 2. Patient Relations Management II | Review the related resources |
| 3 | 3. Basic definitions related to medical records, definitions of document and medical documentation, importance and value of medical documentation. | Review the related resources |
| 4 | 4. Historical background of medical records, use, analysis and development of medical records. | Review the related resources |
| 5 | 5. Tasks, qualifications and importance of medical secretaryship | Review the related resources |
| 6 | 6. Data, information and information system | Review the related resources |
| 7 | 7. Main components of patient file archieves in health institutions | Review the related resources |
| 8 | 8. Organization, functions, budget and committee of archieve | Review the related resources |
| 9 | 9. Numeration, putting in order and file of patient records | Review the related resources |
| 10 | 10. Indexes for patient files, physians, diseases and operations, sytems for indexes | Review the related resources |
| 11 | 11. Jurisprudence side of patient files, information demands of official authorities, contracted institutions, patients and patient's relatives | Review the related resources |
| 12 | 12. Computer usage in patient file archieves | Review the related resources |
| 13 | 13. Prefixes, stems and suffixes of medical terms | Review the related resources |
| 14 | 14. International classification of diseases and medical interventions | Review the related resources |
| Resources |
| Lecture Notes |
| Uçmaz R. Tıbbi Dokümantasyon 1, Uludağ Üniversitesi Meslek Yüksekokulu Yayınları, Bursa, 2004. Uçmaz R. Tıbbi Dokümantasyon 2, Uludağ Üniversitesi Meslek Yüksekokulu Yayınları, 2004. Göçmen E., Tıbbi Kayıtların Tutulması ve Hukuki Sorumluluk, http://www.hastaninhaklari.com/tibbikayitlarintutulmasi.htm Yılmaz A., Kaplan A., Sincan M., Elektronik Hasta Kayıt Sistemine Kavramsal Bir Yaklaşım http://www.sabem.saglik.gov.tr/Akademik_Metinler/goto.aspx?id=2440 Di Lima S.N., Johns T.L. "Health Information Management" AspenPublication, Maryland, 1998. ICD10.CM International Classification of Disseases 10 TH Revision, Tıbbi Terminoloji, Prof.Dr.Adil Artukoğlu Tıbbi Dokümantasyon, Prof.Dr.Adil Artukoğlu, Arşiv Binaları ve techizatı, MichealDuchein, Çeviren : Cemil Göker Kadir Sümbüloğlu, Vildan Sümbüloğlu, Tıbbi Dokümantasyon, Somgür Yayıncılık, Ankara |
Course Contribution to Program Qualifications
| Course Contribution to Program Qualifications | |||||||
| No | Program Qualification | Contribution Level | |||||
| 1 | 2 | 3 | 4 | 5 | |||
| 1 | PQ-1. Learns the national health conditions and the development, implementation and performance evaluation of appropriate health policies, as well as the theoretical and practical knowledge of organization and management of the health sector. | X | |||||
| 2 | PQ-2. Knows and uses theoretical and practical knowledge on business world and management with a critical approach to plan, organize and lead health and health service providers at national and international level. | X | |||||
| 3 | PQ-3. Identifies the relevant job roles in subdivisions of health system organizations and learns about their duties and responsibilities. | X | |||||
| 4 | PQ-4. Knows the social, environmental and behavioral factors related to the development of public and individual health. | X | |||||
| 5 | PQ-5. Applies the knowledge and skills on management of health institutions to manage the functions such as management, production, human resources, finance, accounting, marketing, patient and public relations, quality and patient safety, occupational health and safety, information technologies. | X | |||||
| 6 | PQ-6. Analyzes the information on health management scientifically and interprets their results, creates innovative, ethical, socially responsible and sustainable solutions, by using quantitative, qualitative techniques and digital technology innovatively for problem solving and exploiting opportunities in health management. | X | |||||
| 7 | PQ-7. Decide independently and demonstrates leadership qualities in identifying health management problems, develops proposals for solutions, applies them effectively and efficiently and assesses outcomes. | X | |||||
| 8 | PQ-8. Takes responsibility as an individual and/or team member to solve the problems encountered in managing health institutions. | X | |||||
| 9 | PQ-9. Evaluates the personality, culture and behavioral characteristics of the health institutions’ employees and directs them towards the aims of the institution. | X | |||||
| 10 | PQ-10. Decides on and applies different ways of accessing information. | X | |||||
| 11 | PQ-11. Continuously develops their professional knowledge and skills; be open to change, innovation, entrepreneurship and lifelong learning. | X | |||||
| 12 | PQ-12. Shares the views and suggestions on health management issues in writing and orally with stakeholders and communicates effectively with colleagues using an English level of at least European Language Portfolio B1 General. | ||||||
| 13 | PQ-13. Solves problems using effective communication methods, has the ability to use the language in written and oral communication in a correct and proper manner using the terminology of health institutions. | X | |||||
| 14 | PQ-14. Uses information and communication technologies and computer software at least at the European Computer Use License level. | ||||||
| 15 | PQ-15. Yönetim felsefesini ve yönetimin fonksiyonlarını her bir birime uygun olacak biçimde yönetim uygulamalarına yansıtır. | X | |||||
| 16 | PQ-16. Birey olarak dış görünüm olumlu tutum ve davranışlarıyla kuruma örnek olur; sürekli gelişme ve değişime açıktır. | X | |||||
| 17 | PQ-17. Sağlık yönetimi ile ilgili hukuki düzenlemeler ile toplumsal, bilimsel, mesleki etik ilkelere uygun, ülke ya da dünya genelinde genel sağlık sorunlarına duyarlı davranır, çözüm önerilerini yorumlar ve değerlendirir. | X | |||||
Assessment Methods
| Contribution Level | Absolute Evaluation | |
| Rate of Midterm Exam to Success | 40 | |
| Rate of Final Exam to Success | 60 | |
| Total | 100 | |