UNIT II
MEDICAL RECORDS AND HEALTH INFORMATION
TECHNICIANS II
■ STANDARD COMPETENCE
Understand about MEDICAL RECORDS AND HEALTH INFORMATION TECHNICIANS II
■ BASIC COMPETENCE
1. Understand about Medical records and health information technicians II. The passage discusses about abilities, tasks and job activities
2. Understand how to use pronoun in sentences, paragraph, composition in writing (passive English) and oral (active English).
3. Understand how to use and explain “home remedies” as the motion and its supported vocabularies in telling story to support speaking skill.
4. Can communicate well using “home remedies” As the motion and some supported vocabularies.
■ INDICATOR
After teaching and learning process students expected to be:
1. Able to explain about Medical records and health information technicians II, about ability, task and job activities
2. Able to understand pronoun properly in sentences, paragraph, composition (passive English) and oral (active English).
3. Able to communicate using “home remedies” As the motion and some supported vocabularies.
A. READING
MEDICAL RECORDS AND HEALTH INFORMATION
TECHNICIANS II
After discussing skills and knowledge in the previous unit, in this unit will continue discussing about the two more individual training in medical records namely abilities, tasks and jobs activities of medical records
ABILITIES, TASKS and JOBS Activities (Technical and Functional Expertise)
1. ABILITIES
Note: The technical and functional abilities listed below are based on general occupational qualifications for Medical Records and Health Information Technicians commonly recognized by most employers. Typically, you will not be required to have all of the abilities listed to be a successful performer. Recruitment and selection standards for an individual state job must be based on the specific knowledge, skills, and abilities for that job as indicated in the job announcement and job description in the Employee Work Profile.
The Ability to:
a. Oral comprehension – the ability to listen and to understand information and ideas presented through spoken words and sentences.
b. Written comprehension – the ability to read and understand information and ideas presented in writing.
c. Oral expression -- the ability to communicate information and ideas in speaking so others will understand.
d. Information ordering – the ability to arrange things or actions in a certain order or pattern according to a specific rule or set of rules (e.g., patterns of numbers, letters, words, pictures, mathematical operations).
e. Near vision – the ability to See details at close range (within a few feet of the observer).
f. Speech clarity – The ability to speak clearly so others can understand you.
g. Category flexibility -- the ability to generate or use different sets of rules for combining or grouping things in different ways.
h. Speech recognition – the ability to Identify and understand the speech of another person.
i. Written expression – the ability to communicate information and ideas in writing so others will understand.
j. Selective Attention -- The ability to concentrate on a task over a period of time without being distracted.
k. The ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem.
2. TASKS
Note: The following is a list of sample tasks typically performed by Medical Records and Health Information Technicians. Employees in this occupation will not necessarily perform all of the tasks listed.
Tasks
Protect the security of medical records to ensure that confidentiality is maintained. Process patient admission and discharge documents. Review records for completeness, accuracy and compliance with regulations. Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts. Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures and treatment into computer. Release information to persons and agencies according to regulations.
Plan, develop, maintain and operate a variety of health record indexes and storage and retrieval systems to collect, classify, store and analyze information. Manage the department and supervise clerical workers, directing and controlling activities of personnel in the medical records department. Transcribe medical reports. Identify, compile, abstract and code patient data, using standard classification systems.
Resolve/clarify codes and diagnoses with conflicting, missing, or unclear information by consulting with doctors or others to get additional information and by participating in the coding team's regular meetings. Train medical records staff. Assign the patient to one of several hundred "diagnosis-related groups", or DRGs, using appropriate computer software. Post medical insurance billings. Process and prepare business and government forms. Contact discharged patients, their families, and physicians to maintain registry with follow-up information, such as quality of life and length of survival of cancer patients.
Prepare statistical reports, narrative reports and graphic presentations of information such as tumor registry data for use by hospital staff, researchers, and other users. Consult classification manuals to locate information about disease processes. Compile medical care and census data for statistical reports on diseases treated, surgery performed, and use of hospital beds. Develop in-service educational materials.
Plan, develop, maintain and operate a variety of health record indexes and storage and retrieval systems to collect, classify, store and analyze information. Manage the department and supervise clerical workers, directing and controlling activities of personnel in the medical records department. Transcribe medical reports. Identify, compile, abstract and code patient data, using standard classification systems.
Resolve/clarify codes and diagnoses with conflicting, missing, or unclear information by consulting with doctors or others to get additional information and by participating in the coding team's regular meetings. Train medical records staff. Assign the patient to one of several hundred "diagnosis-related groups", or DRGs, using appropriate computer software. Post medical insurance billings. Process and prepare business and government forms. Contact discharged patients, their families, and physicians to maintain registry with follow-up information, such as quality of life and length of survival of cancer patients.
Prepare statistical reports, narrative reports and graphic presentations of information such as tumor registry data for use by hospital staff, researchers, and other users. Consult classification manuals to locate information about disease processes. Compile medical care and census data for statistical reports on diseases treated, surgery performed, and use of hospital beds. Develop in-service educational materials.
3. Job Activities of Medical Records
a. Getting information -- observing, receiving and otherwise obtaining information from all relevant sources.
b. Interacting with computers- using computers and computer system (including software and hardware) to program, write software, set up functions, enter data or process information.
c. Communicating with supervisors, peers, or subordinates- providing information to supervisors, co-workers and subordinates by telephone, in written form, e-mail, or in person.
d. Updating and using relevant knowledge – keeping up-to-date technically and applying new knowledge to your job.
e. Evaluating information to determine compliance with standards.-Using relevant information and individual judgment to determine whether events or processes comply with laws, regulations or standards.
f. Documenting/ recording information – entering, transcribing, recording, storing, or maintaining information in written or electronic/magnetic form.
g. Establishing and maintaining interpersonal relationships- developing constructive and cooperative working relationships with others, and maintaining them overtime.
h. Handling and moving objects- using hands and arms in handling, installing, positioning and moving materials and manipulating things.
i. Organizing, planning, and prioritizing work- developing specific goals and plans to prioritize, organize, and accomplish your work.
Exercises
I. Answer these questions below!
1. In your opinion, what is the most important task of medical record? Why? Please explain it clearly!
2. In the ability parts, medical record coder must be communicative, can you explain why he/she must be communicative?
3. Do you think English is Important for medical recorder? Why do you think like that?
4. From the explanation of the abilities above, what kind of characteristic must be had by medical record coder?
5. Which one is more important, ability or diploma? Why?
6. Explain about the job activities of medical records! Do you think, those are easy jobs or not? Why?
II. Here are some words from the passage above. There are some verbs and nouns, please differ which are verbs or nouns! After finding them, make a sentence for each verb using present tense and past tense.
1. Announce / announcement
2. Involve
3. Necessary
4. Ensure
5. Confident and confidentially
6. Discharge
7. Compliance
8. Accuracy
9. Improve / improvement
10. Treat/ treatment
11. Observe
12. Obtain
13. Provide
14. Perform
15. Maintain
16. Determine
17. Comply
18. Establish
19. Manipulate
20. Accomplish
III. Memorize the tasks and job activities of medical records above and look for some other tasks that you have known!
B. GRAMMAR
PRONOUNS
There five forms of pronouns in English namely Subject pronouns, complement pronouns (object pronouns), Possessive pronouns, Possessive adjective and Reflexive pronouns.
1. Subject Pronouns
Subject Pronouns are used as a subject and in the subject position of a sentence or after than, as, that, and after the Verb are.
| I You He She It | We You They |
For example:
| I am going to the store She and I is sad | We have finished our homework We students are busy |
It was she who called you (after the verb be)
2. Complement Pronouns
Complement pronouns occur in complement position or in object position
| Subject pronouns I You He She We They If | Complement pronouns Me You Him Her Us Them It |
Example for complete pronouns;
· She called me yesterday.
· The teacher gives them a duty
· John told her a story.
3. Possessive Adjective
Possessive adjective is not the same as possessive pronoun. Possessive forms indicate ownership. These are the possessive pronouns.
| Subject pronouns I You He She We They If | Possessive Adjective My + noun Your + noun His + noun Her + noun Our + noun Their + noun Its + noun |
Example of possessive adjective;
o This is not my book
o The cat has injured its foot
o They boy broke his arm yesterday
4. Possessive Pronouns
The pronoun cannot precede a noun because these pronouns replace the noun.
| Subject pronouns I You He She We They If | Possessive Adjective Mine = My + noun Yours = Your + noun His = His + noun Hers = Her + noun Ours = Our + noun Theirs = Their + noun Its = Its + noun |
Example of possessive pronoun;
| This is my book Your teacher is the same as his teacher Our book are heavy | Ø This is mine Ø Yours is the same as his Ø Ours are heavy |
5. Reflexive Pronoun
These pronouns usually follow the verb and indicate that the subject is both giving and receiving the action.
| Subject pronouns I You He She We They If | Possessive Adjective Myself Yourself Yourselves Himself Herself Ourselves Themselves Itself |
Note : in the plural self changes to selves
· John bought him a car (him = another person)
· John bought himself a car (himself = John)
Examples of reflexive pronoun;
§ I washed myself
§ He himself has done the duty
§ The students themselves decorated the room
§ She served herself in the café.
Exercise;
ª Circle the correct form of the pronoun or possessive adjective in the following sentences.
1. I go to school with (him/he) every day
2. I see (her/she/herself) at the bank
3. She speaks to (we/us/ourselves) every morning
4. Isn’t (she/her) a nice person?
5. (he/him) is going to Jakarta on vocation
6. (she/her) and John gave me money
7. (yours/your) record is bad and (my/mine) is too
8. I hurt (my/mine/the) leg
9. John bought (himself/herself/his self) a new bicycle
10. John (he/himself) went to the meeting
EXERCISE
1. Translate the following sentences into English
Nama saya Herla. Saya tinggal di jalan Veteran nomor 2 Surakarta. Saya belajar di APIKES CITRA MEDIKA SURAKARTA semester I. Saya mempunyai seorang kakak laki-laki dan seorang adik perempuan. Kakak saya Vino. Ia belajar di STIMIK DUTA BANGSA. Ia pergi ke kampus dengan sepeda motor. Adik saya Kanza. Ia belajar di SD KENAGAN. Kanza pergi ke sekolah dengan becak. Ia selalu memakai baju putih dan rok merah. Ayah saya dan ibu saya guru. Mereka mengajar di SMU III. Mereka selalu pergi ke sekolah bersama-sama. Kami tidak pernah saling bertengkar. Kami selalu bahagia.
2. Translate the following sentences into English
Santi dan Dina adalah teman akrab. Mereka duduk di kelas yang sama. Mereka sering saling mengunjungi. Ketika Santi berumur delapan tahun, ibunya melajirkan seorang bayi. Santi sangat bahagia. Ia selalu bercerita tentang adiknya kepada Dina. Dina merasa iri karena Dina tidak mempunyai seorang adik. Santi berkata “Adik saya bertambah berat, beratnya 250 gram minggu ini.” Dina menjawab “Ah, itu biasa. Saya tahu bayi bertambah berat 8 kilogram setiap hari.” “Oh, itu tidak mungkin, “jawab Santi. “itu sangat mungkin. Itu bayi gajah,” jawab Dina.
3. Write an interesting story about your experience. Tell the story in front of the class.
Each the following sentences contain at teats one subject or object pronoun, Circle the pronouns. Then indicate if the sentences are correct (C) or incorrect (I).
| …….. …….. …….. …….. …….. ……. ……. ……. ……. ……. | 1. The worst problem with it is that he cannot arrive. 2. They saw Steve and I at the movies last night after class 3. Perhaps you would like to go to the seminar with they and their friends 4. The mother took her son to the doctor’s office because he was feeling sick 5. I did not know that you and her were working together on the project 6. She did not buy the sweater because it had a small hole in it 7. The man leading the conference gave me all the information I needed to make a decision 8. The cards attaching the computer to its printer need to be replaced before them wear down any further 9. He is going to the party with you and me, if you do not mind 10. You and her ought to return the books to the library because they are already overdue |
4. Each the following sentences contain of one subject or object pronouns, Circle the pronouns. Then indicate if the sentences are correct (c) or incorrect (I).
| …….. …….. …….. …….. …….. ……. ……. ……. ……. ……. | 1. If she borrows your coat, then you should be able to borrow her. 2. Each pot and pan in her kitchen has it own place on the shelf. 3. Mary and Mark invited theirs parents to see their new apartment. 4. When my roommate paid her half of the rent, I paid mine. 5. All students need to bring their own pencils and answer sheets to the exam. 6. All of her secretaries are working late tonight to finish her report. 7. The horse trotting around the track won it’s race a few minutes ago. 8. Before the report is finalized, the information in their notes and our must be proofed. 9. She worked all day cooking food and making decorations for her son’s birthday party. 10. The whether in the mountains this weekend will be extremely cold, so please take yours heavy jackets? |
C. SPEAKING
HOME REMEDIES
When people have a cold, a fever or flu, they usually go to the doctor for help or they get some medicine from the drugstore. But many people also use some remedies for common illnesses.
Lots of people drink hot chicken soup when they have a cold. They find it clears the head and the nose. Some people rub oil on the chest for a cold. Other people drink a mixture of red pepper, hot water, sugar, lemon juice, and milk or vinegar. Here are some simple home remedies.
Bee stings and insect bites: wash the sting or bite. But put some meat tenderizer on a handkerchief and then put it on the bite for half an hour.
Burns : put the burn under cold water or put a cold handkerchief on it. But don’t put ice on the burn.
Coughs : drink warm liquids or take some honey.
Indigestion: drink some water with a teaspoon of baking soda in it.
Insomnia : drink a large glass of warm milk.
Development:
Talk more about other minor health problems you or your friend experienced.
-stomachache
-hangover
-poisoned
-hiccups
-twisted/sprained
-flu
-indigestion
-burn
-sore lips
- bee sting
D. WRITING
Translate these forms into good English and fill in the forms from your friend’s data. After you have finished getting the data, retell the interview!
RUMAH SAKIT CITRA MEDIKA SURAKARTA
| ANAMNESIS | Ruang : | Nomor RM : |
| Nama : | Umur : Lk/Pr | |
| KELUHAN UTAMA : KELUHAN TAMBAHAN : | ||
|
| ANAMNESIS | Ruang : | Nomor RM : | |||||||||||
| Nama : | Umur : Lk/Pr | ||||||||||||
| Tanggal : Jam : | Jenis kelamin : ………………Berat badan : ………..Nadi : ……… Tinggi badan : ……… Suhu : ………… Pernapasan : …………… Tekanan darah : ……………… | ||||||||||||
| | KESAN UMUM | | | ||||||||||
| Tampak sakit Pucat Sesak Lain-lain | Kesadaran Gizi Kejang | ||||||||||||
| | KULIT | | |||||||||||
| Warna Pigment Petechiace Ecchymosis Kuku | Rambut Basah/Kering Turgor Erupsi Lain-lain | ||||||||||||
| | KEPALA | | |||||||||||
| Bentuk | Lain-lain | ||||||||||||
| | MATA | | |||||||||||
| Ptosis Exophthalmus Tekanan intra ocular Lapangan penglihatan Palpebra Conjunctiva Lain-lain | Gerakan bola mata Sclera Pupil Lensa Cornea Fundus | ||||||||||||
| | TELINGA | | |||||||||||
| Membrane tymphani Pendengaran | Mastoid Lain-lain | ||||||||||||
| | HIDUNG | | |||||||||||
| Rongga hidung Mukosa | Septum Lain-lain | ||||||||||||
| | MULUT | | |||||||||||
| Bibi Gusi Palantum durum/molle Mukosa pipi Dasar mulut Lain-lain | Gigi telinga Kelenjar ludah Lidah Kelenjar sub-mandibularis | ||||||||||||
| | TENGGOROKAN | | |||||||||||
| Tonsil Lain-lain | Pharynx | ||||||||||||
| | LEHER | | |||||||||||
| Pembuluh darah Desakan venosa Trachea Kelenjar thyroid | Tumor/Lymphonodi Kaku leher Lain-lain | ||||||||||||
| | DADA | | |||||||||||
| Bentuk Simetri | Pernapasan Lain-lain | ||||||||||||
| | MAMMAE | | |||||||||||
| Benjolan Pernanahan | Putting susu Lain-lain | ||||||||||||
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