Medical Scribe Syllabus

MEDICAL SCRIBE TRAINING COURSE SYLLABUS

What Is Medical Scribing:

Information managers, Medical scribes work at documenting medical provider dictation and activities, allowing providers to spend more time with patients. They accurately document physician or other provider dictation and activities, allowing providers to spend more time with patients. They are trained medical information managers, who specialize in charting physician-patient encounters during medical examinations, and work either onsite or from a remote facility.

Scribes can provide assistance in navigating the electronic health record and locate test or laboratory results and other information. They can also support workflow and documentation for coding of medical records. Medical Scribing is a great new career with more and more providers requesting their services.

A thorough knowledge of medical terminology is required, (included in the training), as well as coding understanding and ability (coding is included in the training). Good keyboard skills and a knowledge of various computer programs is useful.

What is Included? The Course has 3 Modules:

MODULE 1 – Medical Terminology

      Chapter 1. Language Origins, Etymoloy

 

      Chapter 2. English Grammar 101

 

      Chapter 3. Medical Words, Blueprints, Nuts and Bolts

 

      Chapter 4. Dynamics of Medical Vocabulary & Word Structure

 

      Chapter 5. Body Dynamics

 

      Chapter 6. Medical Instruments and Equipment

 

      Chapter 7. Medical Specialties and Specialists

 

      Chapter 8. Diagnostic Medicine

 

      Chapter 9. Abbreviations

 

      Chapter 10. Anatomy and Physiology

 

      Chapter 11. Pharmacology

 

    Chapter 12. Just For Fun

MODULE 2 – Medical Records
Chapter 1 Medical Records
A. Electronic Medical Records
B. Electronic File Transfer
C. Confidentiality
D. Data Entry
Chapter 2 Medical Reports, Formats and Types
A. Medical Dictation
B. Report Types
C. Outpatient Reports
D. Correspondence
E. Inpatient Reports
F. Operative Report
G. Discharge Summaries
H. Consultations
I. Autopsies
J. Interpreting Medical Records & Dictation


MODULE 3-MEDICAL CODING

      PART 1

 

      Introduction

 

      Chapter 1 – Industry History and Codes

 

      A. ICD Codes

 

      B. CPT Codes

 

      C. HCPCS Codes

 

      D. Evolution of Coding

 

      Chapter 2. The Coder

 

      A. Private Practice

 

      B. Hospital Services

 

      C. Coder Responsibility

 

      D. Ethical Standards

 

      E. Understanding What is Coded

 

      F. Documentation

 

      G. Medical Necessity

 

      Chapter 3. ICD-9 Coding

 

      A. ICD-10 Coding

 

      B. Using Reference Books

 

      C. General Coding Guidelines

 

      Chapter 4. CPT Coding

 

      A. Types of Services

 

      B. CPT Coding Book Guidelines

 

      C. Modifiers

 

      D. CPT Book Sections

 

      E/ Symbols

 

      F. Unlisted Procedures

 

      G. Evaluation and Management

 

      Chapter 5. Software

 

      Chapter 6. Legal Issues

 

      PART II

 

      Applied Coding Practicum

 

      A. ICD-9 and ICD-10 Coding

 

      B. CPT Coding

 

      C. Reports 2 through 63

 

      D. Evaluation and Management Reports

 

      E. Supply Codes, APC, PCS

 

    F. Appendix

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