HCDS 1504 - Healthcare Documentation Specialist I

1. Demonstrate correct English usage, applying the rules of proper grammar, spelling, and style references and other resources.
2. Demonstrate the ability to operate designated equipment for Healthcare Documentation Specialist, demonstrating good ergonomic habits. 
3. Accurately transcribe and/or edit documents from a variety of medical specialties, with and without accents and dialects, using appropriate formats.
4. Use language skills and medical knowledge to appropriately edit, revise, and clarify documentation, without altering the meaning.
5. Recognize, evaluate, and interpret inconsistencies, discrepancies, and inaccuracies in documentation.
6. Evaluate the accuracy of healthcare documentation.
7. Recognize situations requiring assistance from supervisor, co-worker, or originator in order to understand dictation and transcribe/edit reports.
8. Analyze and provide solutions to common ergonomic problems in the work environment.
9. Identify and use appropriate references.
10. Demonstrate the ability to use medical references and other resources for research purposes.
11. Demonstrate the ability to operate Microsoft Word processing software including short cut keys and time-saving techniques learned in the Technology Concepts in Healthcare Documentation Specialist (HCDS 1110) course.
12. Accurately transcribe authentic medical dictation through the application of the competencies specified in the categories of Medical Knowledge including  context (utilizing the correct term in the correct context) and sound  discrimination (building listening skills and learning to discern discreet sounds) at a beginning level..
13. Accurately transcribe a variety of medical reports by dictators with and without accents and dialects. The dictation assigned will be representative of a variety of medical specialties. Transcription assignments are not limited to, but  will include the following report types: 

a. History & Physical

b. Discharge Summary

c. Consultation Report

d. Office Note

e. SOAP Note

f. Letter

g. Emergency Department Notes

14. Select correct format for the above-mentioned report types.
15. Apply medicolegal concepts to Healthcare Documentation Specialist.
16. Practice professional and ethical conduct.
17. Utilize language skills and medical knowledge to edit, revise, and clarify appropriately, while transcribing beginning medical dictation without altering the meaning of the document or changing the dictator’s style.
18. Meet progressively demanding productivity standards. (Increase transcription productivity over the course of the semester.)