Medical Scribe Specialist

Hours: 408 / Access Length: 12 Months / Delivery: Online, Self-Paced

Course Overview:

The Medical Scribe course bundle will prepare you to work in medical scribing by exploring the role of the scribe on the healthcare team, legal and health issues with scribing, and the construction of healthcare notes. Further, you will review body systems and their corresponding symptoms and problems that you may need to be aware of as a medical scribe. You will have a chance to practice scribing and review sample scenarios to allow for practical application of what you have learned.

The Medical Scribe bundle includes the following courses:

• Medical Scribe
• Medical Terminology - Root Terms and Word Associations
• Anatomy and Physiology
• Certified Electronic Health Records Specialist

This course prepares a student to take the American Healthcare Documentation Professionals Group ™ (AHDPG) Medical Scribe Certification Exam (MSCE™) and the National Healthcare Association (NHA) Certified Electronic Health Records Specialist national certification exams.

Course Outline:

Medical Scribe Curriculum:

Lesson 1: Healthcare Providers and the Role of the Medical Scribe

This lesson introduces the role of providers and medical scribes in patient care. Types of providers are reviewed as well as the primary responsibilities of a medical scribe.

Lesson 2: Healthcare Law and Ethics

This lesson explains the use of the healthcare record for legal and compliance reasons. Legal aspects of healthcare are also covered, including consent, confidentiality, and fraud and abuse.

Lesson 3: Scribe Safety and Infection Control

Lesson 3 will introduce you to the practice of infection control. Measures to ensure medical scribe safety will also be covered.

Lesson 4: The Health Record and Notes

This lesson begins the lessons on health record documentation. The electronic health record and the various code sets will be discussed.

Lesson 5: Anatomy of a Provider Note

Provider notes are the focus of this lesson. One of the most important, the history and physical, is discussed in detail. Other topics include precharting, chief complaints, and medical decision making.

Lesson 6: Synthesis of a Patient History of Present Illness

This lesson covers the documentation of a present illness. The use of a template will be discussed, to ensure an accurate and informative history.

Lesson 7: Documenting Diagnostic Tests and Therapeutic Procedures

This lesson reviews how to document diagnostic tests and procedure elements. The ECG is covered, along with other diagnostic, therapeutic, and surgical procedures.

Lesson 8: Orders and Disposition Documentation

Lesson 8 covers the various provider orders, including prescriptions, and the disposition of the patient from the medical facility.

Lesson 9: Medical Terminology and Abbreviations

This lesson reviews medical terminology by using word parts and abbreviations. It is imperative that a medical scribe use correct terminology when documenting patient care. This lesson will cover how to build and define medical terms by using the parts of the word.

Lesson 10: Constitutional Health

In this lesson, you will learn about the "constitutional" body system, referring to a person's overall health and appearance. This includes vital signs and other results from a physical exam.

Lesson 11: Integumentary System

You will start a review of body systems by exploring the integumentary system, or the skin. This lesson covers an overview of the skin as well as common procedures and problems that can happen to skin. Medical terminology related to this system is also discussed.

Lesson 12: Musculoskeletal System

This lesson details the anatomy and physiology of the musculoskeletal system. Also included is a review of symptoms related to disorders of the musculoskeletal system along with operations, diagnoses, and problems common to this system. Medical terminology related to this system is also discussed.

Lesson 13: Head, Eyes, Ears, Nose, and Throat

This lesson details the anatomy and physiology of the head, eyes, ears, nose, and throat (HEENT). Also included is a review of symptoms related to disorders of these areas along with operations, diagnoses, and problems common to this system. Medical terminology related to this system is also discussed.

Lesson 14: Nervous System

This lesson details the anatomy and physiology of the nervous system. Also included is a review of symptoms related to disorders of these areas along with operations, diagnoses, and problems common to this system. Medical terminology related to this system is also discussed.

Lesson 15: Cardiovascular System

This lesson details the anatomy and physiology of the cardiovascular system. Also included is a review of symptoms related to disorders of these areas along with operations, diagnoses, and problems common to this system. Medical terminology related to this system is also discussed.

Lesson 16: Respiratory System

This lesson details the anatomy and physiology of the respiratory system. Also included is a review of symptoms related to disorders of these areas along with operations, diagnoses, and problems common to this system. Medical terminology related to this system is also discussed.

Lesson 17: Gastrointestinal System

This lesson details the anatomy and physiology of the gastrointestinal system. Also included is a review of symptoms related to disorders of these areas along with operations, diagnoses, and problems common to this system. Medical terminology related to this system is also discussed.

Lesson 18: Genitourinary (Reproductive and Urinary Systems)

This lesson details the anatomy and physiology of the genitourinary system. Also included is a review of symptoms related to disorders of these areas along with operations, diagnoses, and problems common to this system. Medical terminology related to this system is also discussed.

Lesson 19: Hematology and the Lymphatic and Immune Systems

This lesson details the anatomy and physiology of the hematology and the lymphatic and immune systems. Also included is a review of symptoms related to disorders of these areas along with operations, diagnoses, and problems common to this system. Medical terminology related to this system is also discussed.

Lesson 20: Endocrine System

This lesson details the anatomy and physiology of the endocrine system. Also included is a review of symptoms related to disorders of these areas along with operations, diagnoses, and problems common to this system. Medical terminology related to this system is also discussed.

Medical Terminology - Root Terms and Word Associations Curriculum:

Lesson 1: Basic Word Structure

In this lesson, students will learn to divide medical terms into component parts. In addition, students will learn to analyze, pronounce, and spell medical terms using common combining forms, suffixes, and prefixes.

Lesson 2: Organization of the Body

This lesson will provide an overview of the names of the body systems and their functions. Students will identify body cavities and specific organs within them, list the divisions of the back, and identify three planes of the body. In addition, this lesson will prepare students to analyze, pronounce, and spell new terms and apply medical terms in real-life situations.

Lesson 3: Suffixes

In this lesson, students will identify and define useful diagnostic and procedural suffixes. This lesson will also teach students to analyze, spell, and pronounce medical terms that contain diagnostic and procedural suffixes. In addition, students will apply medical terms in real-life situations.

Lesson 4: Prefixes

In this lesson, students will identify and define common prefixes used in medical terms. Students will also analyze, spell, and pronounce medical terms that contain prefixes. Finally, students will apply medical terms in real-life situations.

Lesson 5: Medical Specialists and Case Reports

This lesson will describe the training process of physicians, identify medical specialists and describe their specialties. Students will learn to identify combining forms used in terms that describe specialists and to decipher medical terminology as written in case reports.

Anatomy and Physiology Curriculum:

Lesson 1: Organization of the Human Body

The student will understand the terms and concepts related to healthy human anatomy and physiology, including the body systems and what is necessary for the body to achieve and maintain a healthy state. In addition, the student will be able to list and define terms used to describe position within the body.

Lesson 2: Chemistry, Matter, and Life

The student will have a basic understanding of concepts in chemistry and biochemistry that are essential to study of the human body. They will know about the structure, behavior, and functions of elements, atoms, molecules, compounds, and mixtures, with special focus on water as an essential compound in all living systems. In addition, the student will be familiar with the characteristics and types of organic compounds and their composition.

Lesson 3: Cells and Their Functions

Students will be able to demonstrate knowledge of the structure of cells and the functions of organelles within them. They will be able to explain cell division, the mechanisms of transport across the plasma membrane, the important roles played by proteins, and the functions of different types of DNA and RNA. Finally, they will understand the nature of cancer and its possible causes.

Lesson 4: Tissues, Glands, and Membranes

Students will be able to identify the major tissue groups of the body and describe their locations and functions. Students will be familiar with benign and malignant cancers and their diagnoses and treatment.

Lesson 5: Disease and Disease-Producing Organisms

The student will be able to identify the major sources of disease, particularly infectious disease, and the principle subspecialties of microbiology: bacteriology, protozoology, mycology, and virology. They will also be able to identify the principle parasitic worms and explain how they cause disease. Students will understand the principle methods for controlling the spread of micro-organisms in human populations, and how micro-organisms are cultured and identified in the laboratory.

Lesson 6: Integumentary System

The student will gain an understanding of the critical function of the skin, including its structure (inner and outer layers) and accessory structures (glands, hair, nails). The student will also gain an appreciation for the skin’s role in thermoregulation, protection against infection, protection against dehydration, and sensation. The student will also learn the relationship between skin cancer and sunlight exposure and differentiate between two common forms of skin cancer.

Lesson 7: Skeletal System: Bones and Joints

The student will learn how bones form the skeletal system and how they, along with the muscular system, function to produce movement at the joints. The student will also learn about bone diseases, their origin, their effects on the body, how some bones and joints are repaired, and the effect of aging on bones and joints.

Lesson 8: Muscular System

The student will become familiar with muscle anatomy, in particular the skeletal (voluntary) muscles, and will be able to name and locate them and describe their functions. The student will understand what activates muscles, as well as the sources of energy for muscular contraction and how the energy is delivered and stored, and the effect of various kinds of exercise on muscles. The student will understand how muscles work in groups and how they work with bones as lever systems. Finally, the student will be familiar with muscle disorders and diseases, and the role of exercise in maintaining good health in general and healthy muscles in particular.

Lesson 9: Nervous System - The Spinal Cord and Spinal Nerves

Students will understand the organization and components of the human nervous system, including the spinal cord, neurons, nerves, glial cells, myelin, and neurotransmitters. Students will be able to describe reflex arcs and spinal plexuses. Students will be able to describe some disorders of the spinal cord and spinal nerves and understand the rationale behind lumbar punctures. Students will understand the difference between the sympathetic and parasympathetic nervous systems.

Lesson 10: Nervous System: The Brain and Cranial Nerves

Students will be able to identify the location and function of the structures of the brain, including the meninges, hemispheres, cortex, diencephalon, brain stem, and cerebellum. In addition, students will learn the names and functions of the 12 cranial nerves. Students will become familiar with the common disorders of the brain, and how brain function is evaluated.

Lesson 11: Sensory System

The student will be able to identify and compare and contrast all of the special and general sensory receptors and their functions. The student will be able to describe the principle parts of the structures of the eye and of the ear and their functions. The student will understand the roles of sensory adaptation and pain and will understand how to mitigate pain.

Lesson 12: Endocrine System: Glands and Hormones

Students will be able to identify the glands and hormones of the endocrine system and will understand the functions and effects of hormones, including hormone pathologies. Students will understand the medical use of hormones in combating disease.

Lesson 13: Blood

Students will be able to list and describe the main components of whole blood, including the erythrocytes, leukocytes, and platelets. In addition, they will understand the concepts of blood grouping, transfusion reactions, and Rh compatibility. Students will understand the major blood pathologies and the tests that are used to diagnose blood disorders.

Lesson 14: The Heart and Heart Disease

Students will be able to identify the principal components of the heart and their functions.  They will also gain an understanding of the circulatory, electrocardiac, and musculatory systems, and the pathophysiology of the heart. Finally, the students will be able to describe the cardiac cycle.

Lesson 15: Blood Vessels and Blood Circulation

Students will be able to describe the pulmonary and systemic circulatory systems and their components, including the major veins, arteries, sinuses, and portal systems. Students will understand the factors that influence blood flow, blood pressure, pulse, and capillary exchange. Students will be aware of disorders of the circulatory system, including hypertension, hemorrhage (trauma), and shock.

Lesson 16: Lymphatic System and Lymphoid Tissue

Students will be able to identify and describe the lymph system and its components, including the ducts, nodes, and fluids. Students will become familiar with the major lymph pathologies.

Lesson 17: Immunity

Students will be able to define infection and the human responses to infection, including inflammation and immunity; they will be able to list the components of the immune system and define their functions. Students will understand the difference between natural and artificial acquired immunity and the active and passive forms of immunity and will be able to define the roles of vaccines and immune sera. In addition, students will explore disorders of the immune system and will be able to state the role of the immune system in cancer prevention and transplantation reactions.

Lesson 18: Respiratory System

The student will gain an understanding of the structure and function of the respiratory system, including inhalation and exhalation, the processes of internal and external gas exchange, how gases are transported in the blood, and the regulation of these processes in the brain stem. The student will also understand the effects of a number of diseases that target the respiratory tract, and some of the instrumentation used to treat these diseases.

Lesson 19: Digestive System

The student will gain an understanding of the primary functions of the digestive tract (ingestion, digestion, absorption, and elimination), as well as the components of the digestive tract itself and the accessory organs (salivary glands, liver, gallbladder, and pancreas). The student will also learn about digestive system diseases and disorders.

Lesson 20: Metabolism, Nutrition, and Body Temperature

The student will understand the cellular processes involved in metabolism, including how food is oxidized for energy, the use of nutrients for energy, and the essential amino acids, fatty acids, vitamins, and minerals needed for healthy functioning. The student will also learn the type and amount of fat, carbohydrate, and protein necessary for good health and the disorders caused by poor nutrition. In addition, the student will understand how the body regulates temperature, including the body’s response to excessive heat and cold, and the causes and possible benefits of fever.

Lesson 21: Urinary System

The student will be able to draw a diagram showing how the urinary system functions to eliminate metabolic wastes, water, and salts from the body. Also, the student will be able to name and describe the major organs involved, including the kidneys, ureters, urinary bladder, and urethra, and understand their functions.

Lesson 22: Body Fluids

The student will recognize the importance of water as a solvent, a transport medium, and a participant in metabolic reactions. The student will understand how body fluids are distributed and how water balance is maintained. The student will also become acquainted with the disorders that occur when fluid intake and output are out of balance.

Lesson 23: Male and Female Reproductive Systems

The student will be able to identify the main organs of the male and female reproductive tracts and understand how they function alone and in relation to each other. Specifically, the student will acquire an understanding of the male and female gonads – the testes and the ovaries, their production of sex cells and hormones, the role of the hypothalamus and pituitary, the female menstrual cycle, and the major disorders that affect the male and female reproductive systems.

Lesson 24: Development and Birth

The student will be able to identify the structures of the main organs involved in fetal development and birth and will understand their function. The student will be able to describe the development process—from the fertilization of the egg to the secretion of essential hormones, which induce changes in the uterus and breasts to support the pregnancy, through the four stages of childbirth, and ultimately to the delivery of the fetus. The student will also be acquainted with life-threatening conditions that can harm the fetus and/or the mother, such as infectious diseases, endocrine abnormalities, tumors, and structural problems.

Lesson 25: Heredity and Hereditary Diseases

The student will gain an understanding of the role heredity plays in one’s abilities and characteristics, as well as the role of genes, chromosomes, DNA, and enzymes critical to metabolism. The student will also recognize how defective genes result in hereditary disorders and how progress made in early identification and treatment may help prevent later problems.

Certified Electronic Health Records Specialist Curriculum:

Lesson 1: Introduction to Electronic Health Records

This lesson will explore the history and current use of patient health records, their importance to individuals' health, and their contribution to the healthcare system including documents in medical records, the electronic health record, advantages and disadvantages to using electronic health records.

Lesson 2: Overview of SimChart for the Medical Office

This lesson will review when medical practices go digital and getting comfortable with electronic health records software.

Lesson 3: Privacy, Confidentiality, and Security

This lesson will review in detail the Health Insurance Portability and Accountability Act (HIPAA); the major features of HIPPA including security safeguards and patients' rights under HIPPA; along with how patients can protect their health information.

Lesson 4: Administrative Use of the Electronic Health Record Patient Letter

This lesson will cover the role of the front office assistant, communication in the Medical Office, Incident reports, and managing electronic health records.

Lesson 5: Clinical Use of the Electronic Health Record

This lesson will review the documentation practices in electronic health records while incorporating clinical documentation in the patient record.

Lesson 6: Using the Electronic Health Record for Reimbursement

This lesson will review the healthcare reimbursement process, revenue cycles, coding systems, and potential fraud and abuse cases.

Lesson 7: The Personal Health Record and Patient Portals

This lesson will cover personal health records, what information is included as compared to the medical record, innovative features of personal health records and how to maintain the personal health record using patient portals.

All necessary course materials are included.

Certification(s):

This course prepares a student to take the American Healthcare Documentation Professionals Group ™ (AHDPG) Medical Scribe Certification Exam (MSCE™) and the National Healthcare Association (NHA) Certified Electronic Health Records Specialist national certification exams.

System Requirements:

Internet Connectivity Requirements:

• Cable, Fiber, DSL, or LEO Satellite (i.e. Starlink) internet with speeds of at least 10mb/sec download and 5mb/sec upload are recommended for the best experience.

NOTE: While cellular hotspots may allow access to our courses, users may experience connectivity issues by trying to access our learning management system.  This is due to the potential high download and upload latency of cellular connections.   Therefore, it is not recommended that students use a cellular hotspot as their primary way of accessing their courses.

Hardware Requirements:

• CPU: 1 GHz or higher
• RAM: 4 GB or higher
• Resolution: 1280 x 720 or higher.  1920x1080 resolution is recommended for the best experience.
• Speakers / Headphones
• Microphone for Webinar or Live Online sessions.

Operating System Requirements:

• Windows 7 or higher.
• Mac OSX 10 or higher.
• Latest Chrome OS
• Latest Linux Distributions
  

NOTE: While we understand that our courses can be viewed on Android and iPhone devices, we do not recommend the use of these devices for our courses. The size of these devices do not provide a good learning environment for students taking online or live online based courses.

Web Browser Requirements:

• Latest Google Chrome is recommended for the best experience.
• Latest Mozilla FireFox
• Latest Microsoft Edge
• Latest Apple Safari

Basic Software Requirements (These are recommendations of software to use):

• Office suite software (Microsoft Office, OpenOffice, or LibreOffice)
• PDF reader program (Adobe Reader, FoxIt)
• Courses may require other software that is described in the above course outline.