I. General Information

1. Course Title:
Medical Scribe I

2. Course Prefix & Number:
HINS 1167

3. Course Credits and Contact Hours:

Credits: 3

4. Course Description:

This course will introduce students to healthcare documentation for medical transcription and medical scribe. Students will learn and apply the basics of medical reporting including appropriate formats used, specialized rules of grammar and punctuation specific to medical reports. Emphasis will be placed on acute care and clinic settings. Students will need to have completed HINS 1360 Medical Terminology and HINS 1122 Body Structures and Functions before taking this course.

5. Placement Tests Required:

Accuplacer (specify test):

No placement tests required

Score:

6. Prerequisite Courses:

There are no prerequisites for this course.

7. Other Prerequisites
Students will need to have completed HINS 1360 Medical Terminology and HINS 1122 Body Structures and Functions before taking this course.

9. Co-requisite Courses:

There are no corequisites for this course.

II. Transfer and Articulation

III. Course Purpose

1. Program-Applicable Courses – This course is required for the following program(s):

Medical Scribe, Certificate

 

IV. Learning Outcomes

1. College-Wide Outcomes

College-Wide Outcomes/Competencies	Students will be able to:
Demonstrate reading and listening skills	Interpret verbal/dictated medical visits to apply correct terminology spelling, abbreviations and acronyms.
Analyze and follow a sequence of operations	Demonstrate ability to follow report formatting guidelines including the specialized rules and grammar of medical reports to create correct medical records for inpatient and outpatient settings.
Apply ethical principles in decision-making	Explain the roles and responsibilities of being a medical scribe and healthcare documentation specialist.

2. Course Specific Outcomes - Students will be able to achieve the following measurable goals upon completion of the course:

• Demonstrate computer skills and recognize equipment;
• Create chart notes from recordings using correct capitalization, numbering, punctuation, abbreviations, acronym, symbol and metric measurement rules;
• Proofread and demonstrate using appropriate references to correctly spell both the English and medical terms;
• Describe the content and purpose of the medical inpatient and outpatient reports;
• Edit medical reports without changing the meaning of content dictated or the originator's style; and
• Demonstrate equity practices and professionalism.

V. Topical Outline

Listed below are major areas of content typically covered in this course.

1. Lecture Sessions

1. Career Role and Responsibilities
   1. American Healthcare Documentation Integrity (AHDI) Code of Ethics
   2. AHDI membership and certification
   3. Professionalism
2. Computer Safety
   1. Computer systems
   2. Ergonomics
   3. Security
3. Formats for Reports
   1. Guidelines
4. Transcription Rules
   1. Abbreviations, Acronyms, and Symbols
   2. Numbers
   3. Date and time
   4. Dimensions
   5. Capitalization
   6. Punctuations
   7. Metric measurements
   8. Nonmetric units of measurement
   9. Microbiology grammar
   10. Vital signs
   11. Style Variations
5. Medical Records and Reports
   1. Outpatient medical chart notes
   2. Daily progress notes
   3. History and physical examination reports
   4. Introduction to medical reports
   1. Operative
   2. Discharge summary
   3. Pathology
   4. Radiology
   5. Consultation
   6. Support materials and websites
6. Outpatient Report Creation
7. 1. Integumentary
   2. Digestive
   3. Obstetrics/Gynecology
   4. Pediatrics/Neonatology
   5. Otorhinolaryngology
   6. Ophthalmology
   7. Dentist/oral surgery
   8. Oncology
   9. Hematology/Infectious Disease
8. Acute Care Report Creation
1. Emergency Department
2. Admitting history and physical
3. Consultations
4. Operative Reports
5. Discharge Summaries
9. Correspondence and Business Documents
1. Email
2. Memos
3. Agendas
4. Minutes
5. Policies