HCDS 1305 - Healthcare Documentation Specialist Procedures

Upon completion of this course, students will be able to:

1. Apply correct English usage, including the rules of proper grammar, punctuation, and style, and use of correct spelling and logical sentence structure.
2. Appropriately use and evaluate the reliability of related grammar and style references and other resources for research and practice.
3. Apply correct medical style as defined by authorities such as The AHDI Book of Style for Medical Transcription and/or the AMA Manual of Style, especially rules that specifically apply to medical transcription.
4. Acquire general knowledge of the regulatory and medicolegal aspects of healthcare documentation.
5. Analyze and evaluate oral and/or written expression by listening and reading critically for elements of medical transcription style and standards of practice in accordance to The AHDI Book of Style for Medical Transcription that reflect accurately transcribed medical reports.
6. Understand medical transcription includes procedures such as editing and proofreading transcribed medical reports.
7. Transcribe medical reports employing correct syntax, usage, grammar, and mechanics.
8. Manage and coordinate basic information gathered from multiple sources for the purposes of problem solving and decision-making.
9. Recognize the major report types and describe document formatting guidelines.
10. Apply the rules of spelling.
11. Spell and define commonly used words.
12. Recognize and correct commonly misspelled or misused words.
13. Recognize and appropriately use homonyms, heteronyms, synonyms, and antonyms.
14. Apply proper medical style in the use of arabic numerals, roman numerals, and units of measure.
15. Incorporate medical stylistic rules in transcription of abbreviations, acronyms, and brief forms.
16. Explain and apply the parts of speech, incorporating them in application of the rules of correct grammar, including verb tense and subject-verb agreement.
17. Apply the rules of punctuation in transcribing, writing, and reading.
18. Analyze and correctly transcribe sentences that may be clipped, inverted, or fragmented, in accordance with medical style.
19. Identify and appropriately transcribe jargon, slang, street talk, regionalisms, profanities, obscenities, and vulgarities, in accordance with medical style.
20. Describe, formulate, and organize paragraphs, in accordance with medical style.
21. Employ proper usage and translation of foreign phrases, in accordance with medical style.
22. Identify and use appropriate references and other resources.
23. Demonstrate general knowledge of security, access, and modification of the health record.