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Chapter 2 Career Skills in Health Informatics
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Accuracy and clarity are the most important considerations when
completing forms, but a few guidelines can make this task easier.
• Speak privately with the patient to clarify information given on
the form.
• Fill in all the spaces on the form. Use Ø, N/A, or None when a
question does not apply to the patient.
• Recognize symbols or abbreviations often used in patient records.
Abbreviations for marital status include S, M, W, and D, which
stand for single, married, widowed, and divorced, respectively.
“Living and well” is abbreviated as l and w. “Died” is abbreviated
d, followed by the year of death.
• Family history includes the current health status and past
conditions or diseases of the patient’s parents, grandparents,
sisters, and brothers.
Figure 2.10 A registration
form contains a patient’s
personal information, such
as contact details, age,
and full name. Why is it
important to protect patients’
personal information?
Simulate
EHR