Instructions for Students:

1. Go to TRACS-> Resources -> “Lab: Contents of Medical Record” folder. This folder contains 10 scanned charts.

2. Download the Microsoft Word document, attached with this assignment’s link in TRACS. This document has a section for each patient. This is because the charts are not all the same so the questions you have to answer will vary by patient.

3. Analyze each chart to find the answers to the questions & type your answers in the corresponding section for that patient (e.g. Patient: Alice)

Tips on completing the patient record contents questions: These records are different layouts so read and review the ENTIRE chart since it might be the case that you would find information in different locations. For example: you may find the chief complaint in the discharge summary. It may/may not be labeled “chief complaint” so you will need to know what “chief complaint” means (i.e. the reason the patient was admitted).

Submission: Submit the Microsoft Word document containing all of your answers, in TRACS, as an attachment to this assignment’s link.

I will provide the site and my student login so you can see the documents necessary. It is Tracs, for texas state students. The course is HIM 3463, and the documents needed are in the resources tab. There is one documents for each patient.