HIM 3040 - Medical Transcription
Clock Hours: 66
Delivery Mode
on-ground
Course Description:
This course teaches the student how to transcript medical documentation.
Student Learning Outcomes:
Course Competencies:
1. Specify the background and importance of medical records.
2. Explain the variety of skills that a medical transcriptionist (MT) must have.
a. Identify the certification levels a MT may obtain in this career.
b. List the competency levels of a medical transcriptionist.
3. Define and explain the purpose of a medical report or record.
4. Describe the importance of the emerging use of electronic health records (EHRs).
5. Identify specific HIPAA regulations that affect MTs.
a. Define risk management.
b. Recognize time limits imposed on document insertions into a medical record: turnaround time (TAT).
c. Define privileged and nonprivileged information.
d. Enumerate the guidelines for release of patient information.
6. Explain the importance of subpoenas for patient records.
7. Describe the different types of dictation and transcription equipment.
a. Describe abbreviation expansion programs.
b. Explain various methods to manage and store computer data.
c. Identify types and features of printers.
d. Identify the purpose of a modem.
e. Apply correct ergonomic habits in the work environment.
f. Identify the different categories of speech-recognition systems.
8. Perform the steps of transcription preparation.
9. Specify how fax machines can be used in the transcription process.
a. Identify why and how to dispose of electronic media.
10. Demonstrate the ability to use punctuation marks accurately.
11. Understand the different parts of speech.
12. Demonstrate the ability to capitalize words accurately.
13. Demonstrate the ability to prepare accurately typed material containing numbers, symbols, and abbreviations commonly found in medical writing.
14. Recognize and correctly use metric abbreviations.
15. State the reasons for spelling out abbreviations.
16. Demonstrate the three basic mechanical formats of letter preparation.
17. Demonstrate the ability to paragraph properly and to place a letter attractively on a page.
a. Use a specific letter format when preparing a letter from a draft copy.
b. Understand the rules for properly typing multiple-page letters.
c. Identify the unique format for “To Whom It May Concern” documents.
18. Recognize the use of displayed extract text.
19. Define critical, major and minor errors.
20. Demonstrate the ability to proofread and correct transcripts.
a. Recognize proofreader’s symbols.
b. Demonstrate the ability to proofread and correct documents transcribed by others.
c. Explain the importance of submitting work for quality assurance and evaluation.
d. Recognize transcriptions practices to avoid in order to produce quality documents.
21. Locate the spelling of medical terms by using a medical dictionary.
a. Use cross-references to find medical terms.
b. Name resources for locating newly coined medical terms.
c. Select the proper word form that could be written as one word, two words, or a hyphenated word.
d. Identify French and other unusual medical terms.
22. Analyze ranges in standard laboratory tests
23. Use drug reference books to determine the correct spelling of drug names, to identify generic and brand-name drugs, and to verify dictated dosages.
24. Develop critical thinking skills to determine an unknown word or words by using other words in the context of the document.
25. Understand the rules for making medical and English words plural.
a. Identify adjective and noun endings.
b. Construct plural and adjective endings of medical terms.
26. Recognize when you need to substitute the proper part of speech for a dictated word.
27. Identify and understand similar sounding words that are grammatically different in meaning and use.
28. Match nouns and pronouns with proper singular or plural verbs.
a. Recognize collective nouns.
b. Demonstrate the ability to select proper pronouns.
29. Recognize word hazards.
a. Identify sentences with dangling or misplaced modifiers.
30. Understand the necessity of transcribing accurate patient progress notes.
a. Demonstrate the proper procedure and format for transcribing medical chart notes and progress notes.
b. Recognize and correct any erroneous entries made in the medical record.
c. Specify the basic information found in patient notes in emergency department, medical office, and clinic records.
d. Identify the key components of the electronic medical record and the traditional paper documents.
e. Understand the importance of medical record notes to the billing cycle.
31. Identify the various mechanical formats used to prepare a history and physical examination report.
a. Explain why certain information is obtained from the patient and recorded.
32. Describe the different ways of gathering and dictating vital medical data.
33. Prepare formal history and physical examination reports by using a variety of styles.
34. Understand why the H&P is considered a high-priority document.
35. Know how to find acceptable formats for a variety of reports and medical documents.
36. Recognize the usefulness of a standard macro within a document.
37. Recognize the names of operative procedures, instruments, types of anesthesia, and suture materials, and be familiar with how these terms should be transcribed.
38. Identify any missing documentation that is required in a complete report.
39. Recognize the rules for writing clear and concise business documents.
a. Compose a business email and a business memo.
40. Consider sensitive issues in sending email messages and practice email etiquette.
a. Identify the problems that may arise when sending medical records as email attachments.
b. Understand the importance of maintaining confidentiality in writing and storing email messages.
41. Type an agenda for a meeting.
a. Record, prepare, and type minutes for a meeting in correct format.
42. Demonstrate the use of critical thinking skills in problem solving.
43. Understand the transition from medical transcriptionist to speech recognition editor.
44. Use shortcut keys when transcribing.
45. Properly prepare a discharge summary, operative report, pathology report, radiology report, consultation report, autopsy protocol, and medicolegal report.
46. Prepare a hospital policy document in typical format.
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