Health Sciences Career Field
| Health Information and Medical Records Career Fields |
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| Overview |
Health Information and Medical Records is a hands-on activity to help students learn about some of the work related to the Health Sciences career field. One of the objectives of the activity is to provide the opportunity for students to do work tasks and then to reflect upon those tasks. The exploration activity is set up to be completed in one class period. The activity could used to introduce the career field.
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| Standards |
School Counseling
K-12.3.1 Identify values, attitudes, and beliefs.
K-12.1.1 Develop an awareness of personal abilities, skills, interests, and motivations.
K-12.1.2 Identify personal skills, interests, and abilities and relate them to current career choices.
K-12.1.3 Identify personal preferences and interests which influence career choices and success.
K-12.1.3 Demonstrate how interests, abilities, and achievement relate to achieving career goals.
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Materials and Supplies |
| Handout “Medical Records”
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| Instructions for Educators |
1. Talk with the students/clients about medical records. Discuss how they are created, stored, and used.
2. An optional activity would be to have a medical records technician visit the group.
3. Hand out “Medical Records” and have them study the abbreviations.
4. Have them use the abbreviations to translate the three sample records on “Medical Records Translation”.
5. Once the translations are completed, have them complete “Thinking about Medical Records”
6. Discuss how interest, abilities, and skills are related to career options and choices.
7. Have the students/clients save the “Medical Records Translation” activity in the career portfolios.
8. An optional activity is to have the students/clients, who are interested in this career field, explore occupations related to this activity or the Health Sciences field.
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Medical Records Instruction |
Medical terms and abbreviations are used by doctors in creating medical notes for each patient. Medical records technicians then translate that information into medical records for patients.
Medical records include information about patients' visits to the hospital or doctor. The records contain everything health care workers observe and do to the patient. Medical records technicians organize all this information in a patient's record. They make sure the information is complete and accurate. They may talk with physicians or others to get more information.
Work with a partner or partners to learn the following medical abbreviations and their meanings. You will be asked to translate statements from doctors. They used the following medical abbreviations.
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Abbreviation |
Term |
CA |
carcinoma |
CHD |
coronary heart disease |
c/o |
complains of |
Dx |
diagnosis |
m |
murmur |
MI |
myocardial infarction |
PI |
present illness |
Sx |
symptoms |
PH |
past history |
OR |
operating room |
X-Ray |
radiology |
Lab |
medical laboratory |
Peds |
pediatrics |
ER |
emergency room |
ENT |
ear, nose, and throat |
ICU |
intensive care unit |
SS |
social services |
stat |
immediately |
tabs |
tablets, pills |
g or gm |
grams |
ml |
milliliters |
L |
liters |
oz |
ounces |
CBR |
complete bed rest |
MRI |
magnetic resonance imaging |
TLC |
tender loving care |
Rx |
prescription |
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Medical Records Translation |
Translate the statements below that contain medical abbreviations. Write the statements with no abbreviations. Then the patients would be able to understand the information.
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1. Saw peds patient in ER. C/o severe headache. Sx included nausea and blurred vision. Sent to X-ray for MRI. Dx concussion. Rx CBR and TLC. |
2. Patient c/o chest pains and shortness of breath. PH indicates CHD. Sx indicate possible MI. Put in ICU for monitoring. |
3. Peds patient brought to ER by 13-year-old brother. C/o of object lodged in throat. Sent X-Ray. Called SS to find parents. Called in ENT specialist and reserved OR. |
Thinking about Medical Records |
Yes |
No |
1. This was a challenging activity. |
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2. This was an enjoyable activity. |
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3. This activity helped me understand what I am good at and not so good at. |
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| 4. This activity helped me think about keeping medical records. |
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5. What did you specifically like or dislike about this activity? |
6. Would you be interested in working with medical records? Keeping patient's charts up to date? Sending records to insurance companies? |
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Explain why you are interested or not interested in these options.
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Save these thoughts in your career portfolio. In the future, review your responses and consider if your interests and preferences have changed. Do you still have the same attitude about the health information project? What has stayed the same or changed and why?
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