A Guide to Genetic Counseling, 2nd Edition. Chapter 10: Medical Documentation

This chapter provides detailed discussion on the importance of medical documentation. It discusses the types of medical documentations, recommendations for medical documentation, and how to disclose information contained in medical records. Includes value-free language callout and appendix outlining structure of a patient letter. 

Type Book
CME Available No
Cost $82.99 ebook; $102.95 paperback
Note Textbook chapter
Date of Resource 2009

Genomic Competencies

Experts from the disciplines listed below have tagged this resource as fulfulling genomic competencies.

Genetic Counselor

  • Genetics Expertise and Analysis
    • 3:   Construct relevant, targeted and comprehensive personal and family histories and pedigrees.
      • 3e:   Extract pertinent information from available medical records.
    • 6:   Demonstrate the skills necessary to successfully manage a genetic counseling case.
      • 6c:   Document and present the genetic counseling encounter information clearly and concisely, orally and in writing, in a manner that is understandable to the audience and in accordance with professional and institutional guidelines and standards.
  • Education
    • 15:   Write concise and understandable clinical and scientific information for audiences of varying educational backgrounds.
      • 15b:   Recognize the professional and legal importance of medical documentation and confidentiality.