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


      PART 1




      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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