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May 10, 2024
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2022-2023 Catalog [ARCHIVED CATALOG]
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MEAS 222 - Medical Assisting Scribe Specialist
PREREQUISITES: Program Chair Approval
PROGRAM: Medical Assisting
CREDIT HOURS MIN: 3
LECTURE HOURS MIN: 3
DATE OF LAST REVISION: Fall, 2020
This course provides students with fundamental skills required of a scribe in a medical facility. Students will demonstrate mastery of keyboarding skills emphasizing speed and accuracy. Students will learn the requirements and perform documentation of all the information obtained by the provider during the encounter including the patient history, review of systems, history of present illness, the physical observations of the exam and the provider’s assessment and plan of care. In addition, students will learn the basics of differential diagnoses.
MAJOR COURSE LEARNING OBJECTIVES: Upon successful completion of the course the student will be able to:
- Demonstrate understanding of patient care clinical documentation.
- Apply content associated with medical, legal, ethical, and regulatory requirements of medical care documentation.
- Incorporate acceptable speed and accuracy measures.
- Acquire ability to produce accurate and timely documentation in the following areas:
- Chief Complaint
- History of Present Illness
- Review of Systems
- Physical Examination
- Consultations
- Discharge Instructions
- Acquire knowledge of medical terminology, anatomy, components of the medical record, and requirements of documentation to support services.
- Acquire knowledge of federal initiative requirements.
- Acquire an understanding of the essential elements of documenting a physician-patient and E/M levels.
- Demonstrate knowledge of medical terminology and technical spelling.
COURSE CONTENT: Topical areas of study include -
- Keyboarding Skills
- Patient Care Clinical Documentation
- Regulatory Requirements of Medical Care Documentation
- Privacy, HIPAA, and Professionalism
- Medical Terminology
- Medical Note
- Chief Complaint
- History of Present Illness
- Review of Systems
- Document Consults
- Document Discharge Instructions
- Understanding Acute Medical Care
- Chest Pain Differential
- Strokes and Intracranial Hemorrhage
- Systems-based Medicine
- Cardiovascular, Gastrointestinal, Respiratory, Musculoskeletal, and Urinary Tract Systems
- Medications - Classes and Antibiotics
- Laboratory Results such as CBC, CBC with Differential, BMP
- Billing and Coding
Course Addendum - Syllabus (Click to expand)
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