Write a 1-2 page paper that describes the purpose and contents of some of the types of documentation used in the HIM field. Specify the settings in which these documents would be used.
The paper will analyzes the different types of documentation in the health record. Familiarity with the contents and use of each type of documentation is an important aspect of your role as a HIM professional.
HIM Terminology
Write a short, one-to-two-page paper on some of the types of documentation used in the HIM field. Be sure your paper includes all of the following headings:
• Progress Note.
• History and Physical (H&P).
• Operative Report.
• Discharge Summary.
Under each heading, address each of the following:
• Describe the purpose of the document.
• Detail the contents included.
• Identify settings where the document would be used.
• Written communication: Your paper does not need to be in APA format. It does need to be clear and well organized, with correct spelling, grammar, and syntax, to support orderly exposition of content.
• Title Page: You do not need to include a title page with your paper. You do need to label it HIM Terminology.
• Name: Include your name in the upper right-hand corner on your paper.
• Length: Approximately 1–2 typed and double-spaced content pages in Times New Roman, 12-point font, not including the reference page.
• References: Include a minimum of one citation of peer-reviewed sources in APA format.