Medical Scribe Certification
Become a Certified Medical Scribe

Learn medical scribing and find out how to work as a medical scribe through our online course! Gain practical medical scribe job experience with our medical scribe training program.

Medical Scribe Training
Medical Scribe

Are you looking to get your Medical Scribe Certification? Look no further! Our comprehensive medical scribe training course provides more than 200 hours of content and includes 41 modules dedicated to teaching trainees the fundamentals they need to succeed.

Enroll
  • Earning your Medical Scribe Certification is a great way to give your medical school application a boost and improve your documentation skills.
  • It can also make you more versatile as there are 16 different specialities available with this certification.
  • With our program, you have the opportunity to become a certified medical scribe which could result in career advancement or even new opportunities.
What does a medical scribe do
What is a Medical Scribe?
What is a medical scribe?

A medical scribe helps doctors by writing down what the patient says, the patient's symptoms, and what codes, medications, procedures, and treatments the doctor plans to use.

Medical scribe job description

The medical scribe job description includes recording medical history, orders, testing results, medical decisions, diagnoses, and treatments in medical documents.

What does a scribe do?

Medical scribes help with medical charting, transcription, and documenting medical history and orders. The average salary for a medical scribe is $20 per hour. ScribeAmerica provides good job opportunities for pre-med students.

How can you become a medical scribe

One way to become a medical scribe is to complete medical scribe training or an approved course in medical transcription. Once trained, medical scribes earn salaries up to $50k that are comparable to medical assistants.

The benefits of being a medical scribe
Medical scribe certification
Medical Scribe Salaries

Working as a medical scribe offers salaries higher than most entry-level healthcare positions. Medical scribes can expect to receive an average annual salary of $28,000 to $35,000. Being a medical scribe can be a great premed student job.

Medical Scribe Jobs

Medical scribe jobs are popular and will keep growing for a few years. Scribes who want to work in the medical field for a long time can feel confident that there will always be a job for them. Working as a scribe is a great way to get experience before going into a more difficult medical career.

Jobs for Premed Students

Medical scribe jobs can help you get premed clinical experiences for PA school or medical school. Working with physicians gives you a chance to see the healthcare system and learn more about medicine from experienced practitioners.

Enroll
Medical Scribe Salary
What is a medical scribe salary?

Salary of a medical scribe can vary greatly depending on experience and location, with the median salary being around $35,000 annually. The average scribe medical salary per hour is typically determined by the experience level of the individual and the type of job. Having the proper scribe training can be a great way to help increase a medical scribe's salary.

Enroll
  • Medical scribe salary per hour ranges from $10-$20 per hour.
  • Higher paying jobs may offer more competitive wages such as up to $30-35 per hour.
  • Medical scribe salary in California can make up to $50,000 per year.

Advanced Medical Scribe Syllabus

  • 1

    Chapter 1: Primary Responsibilities of a Medical Scribe and Career

  • 2

    Chapter 2: Overview of Medical Note Taking

    • Advanced Review of Medical Note Taking

    • Introduction to Scribe Practice Scenarios

    • Smartphrases and Dotphrases Practice
  • 3

    Chapter 3: Medical Terminology Certification

  • 4

    10 Patient Cases

    • Case 1: Abdominal Mass

    • Case 2: Abdominal Pain

    • Case 3: Abnormal Lipids

    • Case 4: Abnormal Pulses

    • Case 5: Abnormal Stature

    • Case 6: Acute Kidney Injury

    • Case 7: Amenorrhea

    • Case 8: Animal Bite

    • Case 9: Antepartum Care

    • Case 10: Anxiety
  • 5

    Chapter 4: Scribe Anatomy and Physiology Certification

    • Part 1: Advanced Review of Anatomy & Physiology

    • Part 2: Advanced Review of Anatomy & Physiology

    • Part 3: Advanced Review of Anatomy & Physiology

    • Anatomy and Physiology Scribe Certification Exam
  • 6

    Chapter 5: HIPPA and Patient Safety Certification

    • HIPPA and Patient Safety Review

    • HIPPA and Patient Safety Certification Exam
  • 7

    20 Patient Cases

    • Case 11: Bleeding and Bruising

    • Case 12: Blood Glucose Concerns

    • Case 13: Blood Pressure Concerns

    • Case 14: Breast Cancer

    • Case 15: Cardiac Arrest

    • Case 16: White Blood Cell Abnormalities

    • Case 17: Child and Elder Abuse

    • Case 18: Electrolyte Disturbances

    • Case 19: Failure to Thrive

    • Case 20: Coma, Head Trauma, & Brain Death
  • 8

    Chapter 6: Interviewing and Communication

    • Interviewing and Patient Communication Case Practice

  • 9

    Chapter 7: History of Present Illness

    • Advanced Review of History of Present Illness

    • History of Present Illness Practice Case

    • Medical Note Writing Certification Exam
  • 10

    30 Patient Cases

    • Patient Case 21: Falls

    • Patient Case 22: Constipation

    • Patient Case 23: Contraception

    • Patient Case 24: Fatigue

    • Patient Case 25: Fever and Rash in Children

    • Patient Case 26: Fractures & Dislocations

    • Patient Case 27: Cough

    • Patient Case 28: Gait Disturbance & Movement Disorders

    • Patient Case 29: Generalized Pain & Neuropathic Pain

    • Patient Case 30: Genetic Concerns
  • 11

    Chapter 8: Past Medical History and Review of Systems

    • Review of Past Medical History

    • Application of Other Past History

    • Review of Systems Application Case

    • ROS Practice Patient Case
  • 12

    Chapter 11: Objective Data

    • Vital Signs Application Case

    • Complete Physical Exam Checklist

    • Pocket Guide for History and Physical Exam

    • Lab Values

  • 13

    40 Patient Cases

    • Patient Case 31: Crying, Fussy Child

    • Patient Case 32: GI Bleed

    • Case 33: Dementia and Delirium

    • Patient Case 34: Gynecomastia & Galactorrhea

    • Patient Case 35: Headache

    • Patient Case 36: Depression

    • Patient Case 37: Developmental Delay

    • Patient Case 38: Health Maintenance

    • Patient Case 39: Diarrhea

    • Patient Case 40: Hearing Loss & Deafness
  • 14

    Chapter 12: Emergency and Urgent Care Scribe Certification

    • Advanced Urgent Care Scribe Review

    • Advanced Emergency Medicine Scribe Review

    • Advanced Emergency Medicine Review - Skim this lesson

    • Advanced Urgent Care Medicine Review

    • Emergency Medicine Scribe Certification Exam

    • Advanced Urgent Care Scribe Certification Exam
  • 15

    Chapter 13: Family Medicine and Ob/Gyn Scribe Certification

    • Advanced Family Medicine and Outpatient Medicine Review

    • Advanced Family Medicine Review - Skim this lesson

    • Outpatient and Family Medicine Scribe Certification

    • Advanced Review of Reproductive Disease --Skim this lesson

    • Ob/Gyn Note Cheat Sheet

    • Ob/Gyn Scribe Certification

  • 16

    50 Patient Cases

    • Patient Case 41: Heart Murmur

    • Patient Case 42: Dizziness

    • Patient Case 43: Hematuria

    • Patient Case 44: Drowning

    • Patient Case 45: Hemiplegia

    • Patient Case 46: Dysmenorrhea

    • Patient Case 47: Hemoptysis

    • Patient Case 48: Dysphagia and Dysphonia

    • Patient Case 49: Hirsutism

    • Patient Case 50: Hyper-coagulability

  • 17

    Chapter 14: Cardiology and Pulmonology Scribe Certification

    • Cardiology Scribe Training

    • Advanced Review of Cardiac Disease --Skim this lesson

    • Cardiology Scribe Certification

    • Pulmonology Scribe Guide

    • Advanced Review of Lung Disease --Skim this lesson

    • Pulmonology SOAP Templates

    • Pulmonology and Critical Care Diagnosis/Plan Cheatsheet

    • Pulmonology Scribe Certification Exam
  • 18

    Chapter 15: Endocrinology and Rheumatology Scribe Certification

    • Endocrinology Scribe Training

    • Advanced Review of Endocrine Disease --Skim this lesson

    • Endocrinology Diagnosis and Plan Cheatsheet

    • Endocrinology Note Examples

    • Advanced Review of Rheum Diseases --Skim this lesson

    • Endocrinology and Rheumatology Scribe Certification Exam
  • 19

    60 Patient Cases

    • Patient Case 51: Infant Hypotonia

    • Patient Case 52: Dyspnea

    • Patient Case 53: Dysuria

    • Patient Case 54: Edema

    • Patient Case 55: Childhood Infectious Diseases

    • Patient Case 56: Immunization

    • Patient Case 57: Inattention, Hyperactivity & Impulsivity

    • Patient Case 58: Incontinence

    • Patient Case 59: Infertility

    • Patient Case 60: Jaundice
  • 20

    Chapter 16: Neurology and Ophthalmology Scribe Certification

    • Advanced Ophthalmology Scribe Overview

    • Advanced Review of Ophthalmic Disease --Skim this lesson

    • Common Neurologic Problems

    • Advanced Review of Neurologic Disease --Skim this lesson

    • Ophthalmology and Neurology Scribe Certification
  • 21

    Chapter 17: Gastroenterology and Nephrology/Dialysis Scribe Certification

    • Advanced Review of Nephrology

    • Advanced Review of Renal Disease --Skim this lesson

    • Advanced Review of Gastrointestinal Disease --Skim this lesson

    • Most Common GI Problems - Surgery, Medicine, and Outpatient

    • Gastroenterology Assistant - Scribe Assistant Certification Exam

    • Nephrology Assistant Scribe Certification Exam
  • 22

    70 Patient Cases

    • Patient Case 61: Joint Pain

    • Patient Case 62: Laceration

    • Patient Case 63: Lumps and New Cancer Diagnosis

    • Patient Case 64: Menopause

    • Patient Case 65: Neck Mass and Thyroid

    • Patient Case 66: Newborn Assessment

    • Patient Case 67: Numbness and Sensory Alteration

    • Patient Case 68: Obesity

    • Patient Case 69: Pallor and Plethora

    • Patient Case 70: Palpitations
  • 23

    Chapter 18: Hematology and Oncology Scribe Certification

    • Review of Hematology and Oncology

    • Advanced Review of Hematologic Disease --Skim this lesson

    • Advanced Review of Oncologic Disease --Skim this lesson

    • Hematology and Oncology Scribe Certification Exam
  • 24

    Chapter 19: Surgery and Orthopedic Scribe Review

    • Advanced Review of Orthopedic Surgery - Skim this lesson

    • Advanced Review of Surgery-- Skim this lesson
  • 25

    80 Patient Cases

    • Patient Case 71: Pediatric Emergency

    • Patient Case 72: Pelvic Pain

    • Patient Case 73: Personality Disorders

    • Patient Case 74: Pleural Effusion

    • Patient Case 75: Pruritus

    • Patient Case 76: Psychosis

    • Patient Case 77: Scrotal Disorders

    • Patient Case 78: Seizures

    • Patient Case 79: Sexual Concerns

    • Patient Case 80: Skin Lesions
  • 26

    Chapter 20: Psychiatry, Plastic Surgery, Dermatology Scribe Review

    • Advanced Review of Psychiatric Diseases-- Skim this lesson

    • Advanced Review of Plastic and Reconstructive Surgery -- Skim this lesson

    • Advanced Review of Dermatologic Disease -- Skim this lesson
  • 27

    Chapter 22: Electronic Medical Record Review

    • Inpatient Epic Overview Part 1

    • Inpatient Epic Overview Part 2

    • Inpatient Epic Overview Part 3

    • Inpatient Epic Workflow Tips

    • Inpatient Epic Quick Chart Search

    • Epic ED Note Taking

    • Epic ED SmartPhrases

    • EPIC Ambulatory New Patient Visit

    • Epic Ambulatory Note

    • EPIC Ambulatory Summary

    • Epic Building a Note Template

    • Epic Smart Phrase Overview

    • Epic Smart Phrases and Copying

    • Epic Smartphase Examples

    • Epic Comprehensive Smartphrase List

    • Cerner Certification Overview

    • Cerner Advanced Review Reference Guide

    • Cerner General Overview and Structure

    • Cerner Note Documentation

    • Cerner Complete Note Overview

    • Cerner Autotext

    • Cerner - Autotext Dynamic Documentation

    • Cerner Medication Reconciliation

    • Cerner Order Entry

    • Cerner Eprescribing and Printing Prescriptions

    • Cerner Inpatient - Medication

    • Cerner - Message Center

    • Cerner Patient Scheduling

    • Cerner Outpatient Workflow

    • Cerner Outpatient - Pre-Registering a Patient

    • Cerner Outpatient - Visit

    • Cerner ED Workflow Part 1

    • Cerner ED Workflow Part 2

    • Cerner ED Workflow Part 3

    • Cerner Advanced ED Charting Workflow

    • Cerner Inpatient - Admission

    • Cerner Inpatient - Medications Given and Scheduled View

    • Cerner Inpatient - Discharge

    • Cerner - Documentation and Billing

    • Cerner Workflow Summary Guide

    • Meditech Expanse - Chart Walkthrough

    • Meditech Expanse - Documentation Overview Part 1

    • Meditech Expanse - Documentation Overview Part 2

    • Meditech Expanse - Admission

    • Meditech Expanse - Reviewing Historical Data

    • Meditech Expanse - Chart Review

    • Meditech Expanse - Documenting

    • Meditech Expanse - Order Entry

    • Meditech Expanse - Discharge

    • Meditech ED - WebED Walkthrough

    • Meditech ED - Simple Note

    • Meditech ED - Formatted Phrases

    • CPSI - Overview

    • CPSI - Chartlink Basics

    • Allscripts Overview

    • Allscripts Outpatient Visit

    • Allscripts Outpatient Note

    • Medhost EHR Demo

    • Medhost ED: EDIS Walkthough Part 1

    • Medhost ED: EDIS Walkthrough Part 2

    • Netsmart Avatar Tutorial

    • Netsmart Homecare Tutorial

    • AthenaHealth Homepage/Dashboard

    • Athena - Patient Charting

    • Athena - Problem List

    • Athena - Medication Tab

    • Athena - Results Review

    • Athena - Past Visits

    • Athena - Smartphrase "Macros"

    • Athena - Premade Smartphrases/Macros

    • Athena - Customizing Smartphrases/Macros

    • Athena - Intake

    • Athena - Chart Review

    • Athena - HPI, ROS & PE

    • Athena - Assessment & Plan
  • 28

    93 Patient Cases

    • Patient Case 81: Skin Wounds

    • Patient Case 82: Sleep Disturbances

    • Patient Case 83: Substance Use

    • Patient Case 84: Syncope

    • Patient Case 85: Temperature Regulation Concerns

    • Patient Case 86: Upper Respiratory Symptoms

    • Patient Case 87: Vaginal Bleeding (Pregnancy Negative)

    • Patient Case 88: Vaginal Bleeding (Pregnancy Positive)

    • Patient Case 89: Vaginal Discharge

    • Patient Case 90: Visual Disturbance

    • Patient Case 91: Vomiting

    • Patient Case 92: Weakness

    • Patient Case 93: Weight loss
Medical Scribe Frequently Asked Questions
A medical scribe is a professional who works in the healthcare industry, providing documentation and other administrative support to physicians and other healthcare professionals. Scribes usually have extensive experience working with electronic health records systems and are familiar with medical terminology and abbreviations. Medical scribes also help facilitate patient flow by taking accurate notes during appointments and making sure that all of the necessary paperwork gets completed.
The most obvious benefit of becoming a certified medical scribe is that it can give you better job security since many employers prefer hiring those who have passed a certification exam from the ACMSO. Furthermore, having this type of certification can demonstrate your commitment to high standards for accuracy and professionalism in the healthcare environment. Finally, it can be an advantageous credential on your resume when applying for higher paying jobs in healthcare administration or other related fields since it shows potential employers that you have taken time and effort to gain specialized knowledge about working in the healthcare industry.
The amount of time required to go through the entire process for gaining certification depends largely on how much preparation one puts into studying ahead of time before taking their exam from the NHA or another organization offering certifications for this type of work. Typically speaking though most individuals should be able to pass their exams within 1-4 weeks after beginning their studies provided they devote adequate time towards studying each day/week leading up to their test date(s).
You can gain clinical hours for med school by participating in research studies that involve patients or volunteering at your local hospital/clinic where you help out with various tasks like taking vitals or helping with paperwork. Additionally there are many virtual shadowing opportunities available during this pandemic that allow aspiring doctors the opportunity to observe physicians remotely and gain valuable hands-on experience without exposure risks. Additionally you can take medical scribing courses and work with physicians easily through this route.
In order to be eligible to become a certified medical scribe, you will need to have coursework or training in medical terminology, anatomy, physiology, pharmacology, pathology, EHR software systems, HIPAA regulations, and patient confidentiality/privacy protocols. You will also need to pass an examination administered by ACMSO in order to receive your official certification.
The cost of obtaining certification as a medical scribe varies depending on which organization you choose for your certification exam and whether or not you select any additional courses or training programs offered by the same organization. Some employers may provide tuition assistance so it’s always worth inquiring if that’s an option available at your place of employment before purchasing any materials yourself.
Most established medical schools require applicants to have completed at least 100 hours of clinical experience in order to be admitted into the program. Clinical experience can include shadowing physicians or other healthcare practitioners or volunteering in hospitals or clinics where you observe firsthand how healthcare works. During COVID-19 pandemic many hospitals have implemented virtual shadowing opportunities that allow applicants get valuable hands-on experience without exposure risks.
Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua.
Medical Scribe Course Syllabus
The responsibilities of a medical scribe include recording information from consultations with patients and other practitioners, as well as verifying that all interactions recorded in an EHR/EMR system have been observed. In this module, you will learn what it takes to get started in your career as a health records assistant, including being able to verify every detail during conversations between practitioners and clients or patients.
This chapter provides you with an opportunity to learn the terminology used in science, technology, and medicine. The unit includes a range of terms, from simple symptoms to advanced test terms and names for complex conditions. There are also standard abbreviations.
In this unit, we will be talking about how to keep your patients safe. We will be discussing key concepts in the Health Information Portability Accountability Act (HIPPA) and what constitutes sensitive information or PHI. We will also be discussing how to ensure compliance while handling things like diagnose descriptions and test results.
This chapter provides an overview of some of the most common health complaints, including abdominal pain, constipation, diarrhea, injuries related to falls and strains, insect and animal bites, diabetic and hypertensive complaints, allergies and rashes, common cold cough, fever eye and ear infections, women’s reproductive health issues, as well as antenatal care.
This unit will teach you about the things in a patient's life that usually help doctors understand what is wrong with them and how well they will respond to treatment. This includes things like their past medical history (like health conditions, allergies, and medications), their family medical history, and their current habits (like alcohol and drug use).
In this unit, we cover how to take a patient's vital signs during the initial consultation. Vital signs include body temperature, heart rate, blood pressure, and respiration rate. It is important for scribes to be able to accurately record these measurements in the chart.
In this unit, we will cover the most common laboratory tests and imaging procedures recommended for patients. These tests include blood work-ups, such as a complete blood count (CBC), basic or comprehensive metabolic panel (BMP/CMP), hemoglobin A1C, lipid panel, thyroid stimulating hormone (TSH), prothrombin time (ProT) and urinalysis (analysis of urine). We will also cover sputum, urine, stool and genital cultures. Common imaging techniques include X-rays, mammograms, computerized axial tomography (CAT/CT) scan, magnetic resonance imaging (MRI), positron emission tomography (PET) scan, ultrasound and fluoroscopy.
There are many different types of medical conditions that can show up at an urgent care clinic. Some patients come with life-threatening problems, while others may only need some over-the counter medication for their symptoms to go away in the meantime - but it's important not get too caught up on what type someone presents as soon as they enter your doors! This unit provides guidelines about assessing risk when seeing new clients so you know how urgently each problem needs attention without making assumptions based off outdated knowledge or bias from previous experiences alone
The goal of this chapter is to help you become a better listener and documentation expert. Learn how identify frequently encountered patient RFVs (reason for visit), like muscle pain or high blood sugar levels, in order document them properly so they can be seen more quickly by doctors who know what's going on with their patients!
Hypothyroidism, growth hormone deficiency and Androgen imbalance are all covered in this chapter. There's also a brief discussion on endocrine problems like Cushing’s syndrome or Paget’s disease as well as their treatments.
In this unit, we will take a close look at how digestion works normally, and what goes wrong in abnormal digestion. We will study diseases caused by problems with the structure of digestive organs, and diseases caused by problems with how they work. These include conditions such as GERD (gastroesophagal reflux disease), peptic ulcer disease, inflammatory bowel disease and cancers affecting various parts of the digestive tract. We will also learn about different ways to treat these conditions using drugs and surgery.
This chapter covers the different types of diseases and conditions that are treated by nephrologists. It also gives an overview of the causes, symptoms and treatment options for each condition. Some of the conditions discussed include glomerulonephritis, nephritis and necrosis, Berger’s disease, Alport syndrome, adult polycystic kidney disease, nephrolithiasis (kidney stones) and urinary tract obstruction. The chapter also covers dialysis protocols for different conditions as well as patient needs, including hemodialysis and peritoneal dialysis.
This unit provides an overview of autoimmune disorders, such as hemolytic anemia, MG or myasthenia gravis (with particular coverage of thyroid sub-type Graves disease), rheumatoid arthritis, Sjogren’s syndrome, juvenile idiopathic arthritis, lupus erythematous, scleroderma, ankylosing spondylitis. It also covers the pharmacology of immunosuppressive medications such as TNF-α and IL antagonists (suppressants of Tumor Necrosis Factor alpha and Interleukin), glucocorticoids, DNA-alkylating agents. The unit also differentiates between conditions with and without autoimmune etiologies (e.g., gout versus rheumatoid arthritis), as well as among different autoimmune conditions.
The chapter covers the protocols for various kinds of surgery in detail. This includes both procedural and anatomical requirements. The content covers the gastrointestinal, heart, lung, ENT, genitourinary and neurosurgery fields. Within each field, the protocol covers important precautions, pharmacological support as well as surgical procedures. Additionally, the unit addresses surgical reduction and/or removal of cancerous tissue. A separate section covers protocols and precautions in pediatric surgery.
In this chapter, you will find out all about plastic surgery and its protocols. Topics covered include how to heal a wound properly so it doesn't recur as well as other aspects such us reconstructive surgeries for defects like chest wall reconstruction after being hurt in an accident or following disease where there was once skin loss due too cancer treatment but now has been restored using different types of tissue expanders that help restore what was lost while also giving back hope!
This unit provides a detailed overview of the basics of identifying conditions that present to the dermatology department. The content includes a primer on the structure of the skin and different types of skin cells, as well as different types of skin disturbances (e.g., nodules, pustules, papules, lesions, scabs). The chapter also covers various pathological processes (e.g., spongiotic, psoriasiform, vesicobullous, granulomatous) in depth. Finally, the unit provides an introduction to major types of skin cancers (e.g., basal cell and squamous carcinomas, melanomas).
Trainee scribes are given a comprehensive tutorial on how to navigate through the EPIC EHR system, including an overview of the EPIC interface and important aspects of case documentation. Tips are provided on building efficient workflow using EPIC, with tips on running Quick Chart Search on inpatients, use of SmartPhrases in note taking, setting up note templates for commonly seen medical problems, as well as a separate section on documenting outpatient or Ambulatory cases.
Module 2 will cover everything that goes into a medical note, like what your symptoms are and how you're feeling. You'll learn how to write in traditional SOAP format, which stands for subjective assessment & objective findings. That means only including the important details and leaving out anything extra.
In this module, you will learn about the human body and how it functions. The content covers structural organization at tissue levels as well as functional specialties within organs such as hearts or lungs!
Module 6 is about why it is important to communicate well when you are talking to patients and working with other doctors. It talks about how to listen carefully, ask questions when you need more information, and make sure everyone understands what was said before moving on.
This chapter explains why it is important to write a clear and detailed History of Present Illness (HPI). This includes describing the patient's symptoms, how often they occur, how long they last, and what makes them better or worse.
The chapter talks about an important part of the first meeting with a doctor, when the doctor asks the patient lots of questions about their overall health. This is called a Review of Systems (RoS). The doctor also assesses the patient's mental condition through a Mini Mental Status Exam (MMSE). This information can help the doctor accurately diagnose a medical problem.
This chapter provides an in-depth guide for how to document the results of your detailed physical exam. It includes everything from head tilts and coughs, ear inspection (including outer/middle ages), throat gagging maneuvers when necessary--all with a view towards determining each patient's overall health status.
The next section will teach you how to make an A/P. This is a record of information that needs to be included in order for it be useful, and there are certain standards by which all such documents must meet! Ex: The patient is a [age] year old [male/female]. They are experiencing [symptoms]. Their current medical problems are [problem] with test results of [test results]. They also have a chronic condition of [chronic condition], which has baseline function indices of [baseline function indices]. The likely diagnosis is [likely diagnosis], and the precipitating factor is most likely[precipitating factor]. The exacerbating factors are things that could potentially worsen the patient's condition, and they are as follows: [exacerbating factors]. The recommended medications for this patient are as follows: [recommended medications], and they should also make the following dietary changes: [dietary changes] Finally, they should also make the following lifestyle changes: [self-care, precautions].
The Emergency Department is a chaotic and confusing place. There are so many complaints, each with their own set of protocols to follow! This chapter provides an overview for ED staff members who may not be familiarized in detail on how they should handle different types cases seen there - from acute dehydration or electrolyte imbalance all the way down through hypo-glycemia & hyperglycemia vasodilatory shock/sepsis botulism trauma accidents etc. For every type outlined above (and more), we cover what you'll typically encounter during consultations along side ‘work ups’ which include assessments labs tests scans procedures advice medications dietary care techniques
The Cardiovascular Chapter is a comprehensive guide to the most common heart-related conditions. It includes information on how you can diagnose and treat these issues, as well what assessments are necessary for diagnosis or care recommendations - including an explanation of commonly used terms that might be new outsider medicine readers come across while reading through this text!
The causes of common pulmonary symptoms are discussed in this chapter. Important concepts covered include how to interpret the FEV1/FVC ratio, lung pressure curves and ABGs (arterial blood gases). By end, trainees will be able differentiate between conditions such as asthma or COPD with emphysema because they now know what each diagnosis entails on an airflow level.
This unit will go over the most common CCs that are seen in neurology department. This includes things like vertigo, seizures, and migraines. We will also cover topics like the nervous system, different types of illnesses, and how they impact the brain.
In this unit, trainee scribes learn about how blood is formed, what it is made of, how it flows and how it is used by the body. They also learn about diseases that can happen when something goes wrong with any part of the blood system. These diseases include anemias and thalassemias, thrombotic conditions, bleeding disorders, myeloproliferative disorders, lymphatic system disorders and cancers of the blood and bone marrow. The trainee scribes also learn about different drugs that are used to treat these conditions, as well as how to safely transfuse blood between people.
The unit goes over common problems with people's eyes, including floaters and flashing lights, blurry vision, itching and tearing, red and painful eyes, and headaches. The unit also teaches how to do a vision test, including checking for visual acuity, pupil dilation, and ocular pressure. Additionally, the unit covers the anatomy of the eye and surrounding muscles, as well as major pathologies such as glaucoma, diabetic retinopathy, retinal detachment, AMD or age-related macular degeneration.
This chapter gives an overview of conditions that need orthopedic treatment. This includes reviewing important considerations before beginning treatment, such as HTN (hypertension), diabetes, and coronary disease history. Conditions covered include fractures and dislocations, thrombotic conditions like DVT (deep venous thrombosis) and PE (pulmonary embolism), musculoskeletal traumas, and neurological conditions such as cauda equina syndrome. Orthopedic treatment approaches covered in detail include splinting, casts, traction, and surgical correction. Other processes that are covered include injection, aspiration, electrocautery, and tourniqueting.
This unit will cover a lot of different types of mental disorders, like anxiety disorders, mood disorders, eating disorders, substance abuse problems, personality disorders, and more. We'll also talk about some of the ways that these conditions can be treated, like with different types of therapy or medication. And finally, we'll go over some of the different ways that these disorders are classified.
This unit covers important aspects of documentation for radiological procedures, including the following: The purpose of a scan. For example breast imaging (screening vs diagnostic). The type(s) and number views; multiple scans performed to obtain complete picture inside condition such as chest X-ray or craniotomy with CT scanning technology. Contrast agents used in MRI exams like SPECT.
The unit provides an in-depth walk-through of documenting medical records using the Cerner PowerChart EHR system. The detailed tutorial includes crucial aspects of medical documentation, such as: creating patient IDs and managing provider schedules; building a case record; creating orders, prescriptions and bills; documenting case details within PowerChart; and billing CPT modifier codes. Additionally, the chapter includes tips and tools on improving documentation speed and workflow efficiency.