This course covers the basic understanding, primary responsibilities, concepts and techniques necessary to be an effective and efficient medical scribe. The course covers the medical scribe scope of practice, HIPAA, medical terminology, the medical progress note, documentation requirements, chronic diseases, common medications, common labs, common testing, medical billing and coding and legality as it relates to the medical scribe profession.

Course Objectives

Demonstrate the ability to understand the medical scribe profession and scope of practice

Demonstrate the ability to protect patient privacy and understand HIPAA

Demonstrate the ability to write a complete medical progress note

Demonstrate the ability to understand chronic diseases, medical terminology, common labs, medications and testing as it relates to the medical scribe profession

Demonstrate the ability to perform all duties of a Medical Scribe Examination (MSCE)

Outline of Instruction

Part I. The Medical Scribe in Health Care
Chapter 1: Health Care Providers and the Role of the Medical Scribe
Chapter 2: Health Care Law and Ethics
Chapter 3: Scribe Safety and Infection Control

Part II. Health Record Documentation
Chapter 4: The Health Record and Notes
Chapter 5: Anatomy of a Provider Note
Chapter 6: Synthesis of a Patient History of Present Illness
Chapter 7: Documenting Diagnostic Tests and Therapeutic Procedures
Chapter 8: Orders and Disposition Documentation
Chapter 9: Medical Terminology and Abbreviations

Part III. Body Systems for the Medical Scribe
Chapter 10: Constitutional
Chapter 11: Integumentary System
Chapter 12: Musculoskeletal System
Chapter 13: HEENT (Head, Eyes, Ears, Nose, Throat)
Chapter 14: Nervous System
Chapter 15: Cardiovascular System
Chapter 16: Respiratory System
Chapter 17: Gastrointestinal System
Chapter 18: Genitourinary (Reproductive System and Urinary System)
Chapter 19: Hematology and the Lymphatic and Immune System
Chapter 20: Endocrine System

Contact Hours

173

CEUs

1

Industry Standard, State or National Certification

Certification

American Healthcare Documentation Professionals Group - Medical Scribe Certification Exam (MSCE) or Apprentice Medical Scribe (AMSP)

Website

https://ahdpg.com/certification/medical-scribe-certification-exam-msce/…

Certification Learning Outcomes/Requirements

Completion of Medical Scribe course

CE or CU Articulation

No

Prerequisites

CMA or Medical Terminology NUR-3235E3 or MED-121 and -122 and High School Diploma or GED

Learning Supplies Needed

"The Complete Medical Scribe" - Elsevier E-Book on VitalSource, 3rd Edition ISBN: 9780323812528

Clinical Site/Special Facilities

Individuals who take and pass the MSCE who have less than 200 hours of direct medical scribe experience can earn the credential Apprentice Medical Scribe (AMSP). Individuals who take and pass the MSCE who have 200 hours of direct medical scribe experience earn the Certified Medical Scribe Professional (CMSP) credential. An AMSP candidate who eventually acquires 200 hours of direct medical scribe experience can request an update to the Certified Medical Scribe Professional (CMSP) credential via company website, upon verification by your supervisor.

Requirements for Successful Completion

100% attendance
Overall grade of 80 or better

Accreditation/Special Approval Requirements

N/A

Intended Audience

Persons interested in working in a medical environment as a medical scribe.

Specific Industry or Business Support Needs

N/A

Wake County Need for Industry Positions

N/A

Industry or Job Titles Related to Training Outcomes for Employment

Medical scribe

Related Courses

Course Contact Information

Health Science Non-Degree Programs https://cehealth.waketech.edu
919-747-0140
[email protected]