HCDS 1511 - Healthcare Documentation Specialist II

1. Apply correct English usage and the rules of proper grammar, spelling, punctuation, and will use correct spelling and logical sentence structure.
2. Apply correct medical style as defined by authorities such as AHDI’s The Book of Style and/or the AMA Manual of Style, especially rules that specifically apply to healthcare documentation and editing.
3. Distinguish between or among medical homophones (sound-alikes), commonly confused medical terms, and synonyms.
4. Students will demonstrate a general knowledge of and the ability to operate computers and related technologies.
5. Demonstrate the ability to operate designated equipment for medical transcription and demonstrating good ergonomic habits. 
6. Interpret and accurately transcribe a variety of healthcare reports of intermediate and advanced difficulty.  The reports will be dictated by physicians with and without accents and dialects.  The dictation will be representative of a variety of medical specialties as specified in the course outline to include the following report types:

• History & Physical
• Discharge Summary
• Consultation Report
• Radiology Report
• Pathology Report
• Office Note
• Letter

7. Select correct format for the above-mentioned report types.
8. Meet progressively demanding accuracy standards while transcribing/editing reports of intermediate and advanced difficulty.
9. Meet medical transcription productivity standards demonstrated through timely completion of transcription assignments making use of tools such as expanders, keyboard shortcuts, and macros.
10. Identify and use appropriate references and other resources, whether written or electronic, or Web-based resources while transcribing, proofreading, editing and revising.
11. Demonstrate the ability to proofread and correct transcribed medical reports, including using critical thinking and editing skills.
12. Students will analyze their errors and devise corrective strategies
13. Apply productivity and accuracy standards and definitions.
14. Use language skills and medical knowledge to appropriately edit, revise, and clarify while transcribing/editing original healthcare documentation of intermediate and advanced difficulty, without altering the meaning.
15. Recognize, evaluate, and call attention to medical inconsistencies, discrepancies, and inaccuracies in healthcare documentation while transcribing, without altering the meaning of the dictation.
16. Evaluate the accuracy of healthcare documents of intermediate and advanced difficulty.
17. Recognize situations requiring assistance from supervisor, co-worker, or originator in order to understand dictation and transcribe/edit reports.
18. Define and apply medicolegal concepts to healthcare documents.
19. Define and apply professional and ethical conduct including the AHDI Code of Ethics.
20. Understand general documentation concepts related to optimizing reimbursement.
21. Students will interpret and explain the content of medical records.
22. Identify elements in healthcare documentation practice that affect reimbursement (e.g., completeness, timeliness).
23. Students will appraise, and articulate awareness of, the value of continuing education and professional credentials relevant to healthcare documentation practice.
24. Demonstrate an awareness of the dynamics of the work environment and the importance of professional development.