The Complete Medical Scribe: A Guide to Accurate Documentation

Description:

Expand your career opportunities with this concise, all-in-one guide to a dynamic and growing healthcare career! The Complete Medical Scribe: A Guide to Accurate Documentation, 3rd Edition provides the information you need to document patient health records accurately, thoroughly, and efficiently. Coverage includes activities such as creating a note, recording a patient history and review of systems, documenting diagnostic tests and therapeutic procedures, and noting follow-ups for labs or imaging. A strong foundational knowledge of anatomy and body systems is emphasized. Written by two medical doctors in conjunction with the experts at ABC Scribes, this comprehensive resource will prepare you to become an essential member of the healthcare team in a variety of settings.

Features:

Comprehensive coverage includes everything you need to know to work as a medical scribe, including medical law and ethics, safety and infection control, health record documentation, billing and reimbursement requirements, medical terminology basics, and detailed body system coverage.

Clinical scenarios represent common situations and promote real-world application of the scribe’s function.

Case studies with questions test your comprehension and let you apply your knowledge to the clinical setting.

Review questions and exercises within chapters and online provide opportunities for self-quizzing to identify areas of strength and areas of focus.

Nearly 200 colorful medical illustrations and photos depict subjects such as anatomy and physiology as well as online charting within the electronic health record (EHR).

Detailed instructional videos online simulate medical practice, using real doctor-patient encounters that progress logically through each part of the EHR.

Notes boxes emphasize practice dos and don’ts along with on-the-job realities.

Table Of Contents:

Role of the Medical Scribe

Healthcare Law, Ethics, and Organization

Overview of the Scribe Note

Anatomy of a Provider Note

Synthesis of a Patient History

Additional Functions of the Medical Scribe

Medical Terminology and Abbreviations

The Physical Exam

Integumentary System

Musculoskeletal System

HEENT (Head, Eyes, Ears, Nose, Throat)

Nervous System

Cardiovascular System

Respiratory System

Gastrointestinal System

Genitourinary System

Hematologic, Lymphatic, and Immune Systems

Endocrine System

Chief Complaints

Practice Exercises