I. General Information

1. Course Title:
Medical Scribe II

2. Course Prefix & Number:
HINS 1168

3. Course Credits and Contact Hours:

Credits: 2

Lecture Hours: 2

4. Course Description:

5. Placement Tests Required:

6. Prerequisite Courses:

7. Other Prerequisites
HINS 1164 Applied Medical Terminology HINS 1167 Medical Scribe I

9. Co-requisite Courses:

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

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

• Identify and define the knowledge, skills, abilities, and responsibilities of medical scribes and their role in a healthcare organization;
• Demonstrate creating chart notes from recordings and/or live clinical setting;
• Proofread and demonstrate using appropriate references;
• Identify and recognize the importance of having current medical documentation reference material and how to use them effectively;
• Describe the content of the medical inpatient and outpatient reports; and
• Edit medical reports without changing the meaning of content dictated or the originator’s style.

V. Topical Outline

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

1. Lecture Sessions

1. Common Errors
   • Difficult singular and plural words/phrases
   • Unusual Words
   • The digits
   • Connective Tissues
   • Subjective vs. Objectives
   • Class and Stage
2. Report Format
   • Subjective, Objective, Assessment, Plan (SOAP)
   • History, Physical, Impression, Plan (HPIP)
   • History and Physical Exam
   • Radiology Report or Diagnostic Imaging Report
   • Pathology Report
   • Consultation
3. Case Studies by System and Specialty
   • Cardiopulmonary System
   • Musculoskeletal System
   • Respiratory System
   • Neurology
   • Orthopedics
   • Rheumatology
   • Urology
4. Cardiology
   • Abbreviation, Terminology and Anatomy Review
   • Diagnostic tests
   • Noninvasive and Minimally Invasive Tests & Services
   • Associated Nuclear Imaging
   • Treatment modalities
   • References and Web Sites
   • Reports
5. Neurology
   1. Abbreviation. Terminology, and Anatomy Review
   2. Cranial Nerves
   3. Common Communication Disorders
   4. Neurology Reports
   5. References and Web Sites
   6. Reports
6. Rheumatology
   • Abbreviations, Terminology, and Anatomy Review
   • Diagnostic and Laboratory Tests
   • References and Web Sites
   • Reports
7. Orthopedics
   • Abbreviation. Terminology, and Anatomy Review
   • Bone fracture classifications
   • Types of joints
   • Types of splints
   • References and Web Sites
   • Reports
8. Respiratory/Pulmonology
   • Abbreviation. Terminology, and Anatomy Review
   • Diagnostic and Laboratory Tests
   • Lung Function Tests and Values
   • References and Web Sites
   • Reports
9. Urology
   • Abbreviation, Terminology and Anatomy Review
   • Diagnostic Tests
   • References and Web Sites
   • Reports
10. Chronic Care