This assignment develops skills in conducting chart reviews, both through standardized forms and by presenting findings in a multimedia format. This assignment will help you learn how to extract and communicate key information from medical records, which helps to ensure that the records are complete, accurate, and compliant. Before beginning the assignment, watch the medical records tour for patient Clea Clemens.  

Chart Review #1 Directions:

Download the QI Review form Download QI Review formand complete all areas on the form using the information from patient Jesse Stewart's chart Download Jesse Stewart's chart. Submit your completed form as a word document or pdf.

Grading: 30 possible points, 1 point per answer space

Chart Review #2:

Select a medical record from the Example Medical Records module (located at bottom of the Modules page) and review all documents within the record. Create a PowerPoint presentation with voiceover on each slide that guides viewers through the patient's chart. Submit your presentation as a PowerPoint file (do not convert to PDF as you will lose your voiceover).

Your PowerPoint must include at minimum:

• Chart ID (use file name – if this is missing, I will not grade and you will receive a zero for the entire review!!)
• A brief summary of the patient (demographics)
• History of present illness
• Information from progress notes (how did the patient's hospital stay go)
• Information from orders (what types of medications and other treatments were ordered)
• Description of treatment given, including therapy and/or (operative) procedures
• What did the pathology show if a specimen was removed?
• Was the patient discharged to home or another location? 
• What was the final diagnosis?

Your voiceover must add substantial information beyond what is on the slides – do not read directly off the slides as you will lose points! If your presentation does not include voiceover, you will receive a zero!