Overview
This program provides a comprehensive overview of the skills you need to be a successful medical scribe. We’ll discuss basic medical procedures and walk you through standard administrative duties and documentation processes.
Program Timeline
Our program is divided into 11 bite-sized courses that cover all the necessary skills you’ll need to succeed as a medical scribe.
11 individual courses
8 months of full program access
Study Format
You don’t have to take a sledgehammer to your schedule in order to train for a new career. Our training is available whenever and wherever you’re ready.
Learn from home (or anywhere)
Study online (anytime)
Support
Learning something new is never easy. That’s why we’ll back you every step of the way. Chat with a Career Advisor and let us know how we can help.
One-on-one support
Phone, live chat, and email
Medical Scribe Certification Program Outline
Our program is divided into 11 bite-sized courses that cover all the necessary skills you’ll need to succeed as a medical scribe.
Program Orientation: Medical Scribe
- Initiate Medical Scribe program.
Digital Technology
- Have a basic understanding of the internet and evaluated hardware
- Understand and be able to use various programs and apps
- Be able to explain privacy and digital security in digital technology
- Describe the fundamentals of input and output
- Have an understanding of network devices
- Use technology to help you find a career
Grammar and Punctuation with Medical Examples
- Identify and correctly use each of the parts of speech.
- Recognize proper sentence structure and formatting, including punctuation and capitalization.
Comprehensive Medical Terminology
- Analyze how medical terms are built using common word parts
- Properly spell, define, and pronounce medical terms associated with each of the major body systems
- Identify and define the word parts most frequently associated with the major body systems
- Interpret common abbreviations used in medical terminology and cautions to remember when using them
Anatomy and Physiology
- Identify the structures, locations, and functions of major body systems and the organs that comprise them.
- Explain how the organs of the major body systems interact and maintain homeostasis.
- Compare various risk factors leading to high mortality and morbidity.
- Describe the components of cell structure and their functions.
- Summarize how infectious agents affect cellular growth and function.
- Define basic anatomical terms.
Comprehensive Pharmacology
- Define basic pharmacology terminology.
- Identify U.S. drug laws and explain their importance in patient care and health services documentation.
- Differentiate among drug classifications, routes of entry, mechanisms of action, and therapeutic treatments related to specific body systems and disease conditions..
- Identify medication side effects, precautions, contraindications, and interactions.
- Identify major drug standards, legislation, legal responsibilities of the health care practitioner when dispensing medications.
- Identify the major drug classification systems and differentiate among the various types of drug names with examples.
- Evaluate the standard and online pharmacological references in use today.
- Classify the sources of drugs, examine their pharmacokinetic processes, and analyze the variables that affect drug actions and effects.
- Analyze various drug forms, routes of delivery, and the supplies and techniques necessary for safe and appropriate administration.
- Identify commonly used medications and their characteristics.
- Identify the sources, mechanism of action, and indications for specific drug therapies.
- Analyze the side effects, precautions, contraindications, and interactions for specific medications.
- Assess the factors that influence the absorption and effectiveness of drugs.
- Analyze the physiological effects of prolonged drug use and discuss the responsibilities of a health care practitioner in addressing and treating drug abuse.
- Investigate recent actions taken by the government and by manufacturers for specific drugs.
- Identify the key factors involved in considering drug therapies for older adults.
Comprehensive HIPAA
- Describe HIPAA basics.
- Understand the HIPAA Privacy Rule.
- Understand the HIPAA Security Rule.
- Describe the HITECH Act.
- Explain regulations for business associates.
- Summarize HIPAA documentation and training.
- Review applied HIPAA security for healthcare professionals.
Comprehensive Electronic Medical Records
- Demonstrate how patient records are used and regulated.
- Complete tasks required for scheduling patient appointments.
- Practice clinical information reporting.
- Apply basic coding for reimbursement claims.
- Outline revenue cycle and financial reporting.
Scribe Essentials
- Understand the history of the Medical Scribe industry.
- Understand what a medical scribe is.
- Understand the importance of HIPAA as a medical scribe.
- Underline the medical scribe’s scope of care and ability to maintain integrity and patient privacy.
- Describe the primary roles and responsibilities as a medical scribe.
- Understand the necessary skills of a medical scribe.
- Review do-nots and tips to succeed as a medical scribe.
- Relate to different clinical environments as a member of a multidisciplinary team.
- Understand the different clinical settings.
- Know the difference between outpatient facilities/clinics and the emergency department workflow.
- Apply medical terminology when documenting and communicating among healthcare professionals.
- Review the vital signs.
- Record basic medical abbreviations.
- Illustrate knowledge of common prefixes and suffixes used in medical terminology.
- Distinguish the difference between subjective and objective findings.
- Conduct through documentation of the chief complaint, history of present illness, review of systems, current medication regimen, allergies, medical history and family history.
- Have a baseline understanding of different physical exam findings.
- Understand what information will be added to the assessment and plan.
- Execute the standard order of documentation by using the acronym SOAP.
- Know the common laboratory tests and what they are used to test for in regard to medical decision making.
- Know the common medical imaging and what they are used for in regard to medical decision making.
- Understand vital signs and physical exam findings and how they contribute to medical decision making.
- Identify and document the final diagnosis from the provider.
- Summarize the patient’s disposition, plan and discharge instructions as ordered from the provider.
- Demonstrate active listening skills to document the patient visit.
- Navigate the EHR Go platform and successfully enter the visit information into the EHR system provided.
- Utilize what you have learned in previous courses in this program to practice a “real life” scribing exercise to include medical terminology and pharmacology.
Career Success in Healthcare
- Define “professionalism” and “success” in your own terms.
- Differentiate between long-, medium-, and short-range goals.
- Assess and develop your time management skills.
- Develop plans to enhance your creative and critical thinking.
- Use an effective decision-making process to maximize your chances for success.
- Describe methods to maximize verbal, nonverbal, and written communication.
- Describe the healthcare system.
- Describe and discuss organizational structure, communication channels, and lines of authority.
- Develop an understanding of the factors that affect group dynamics and use these skills to maximize your leadership potential.
- Explain ethics and how they relate to health care professionals.
- Define continuing education, certification, and licensure.
Program Completion: Medical Scribe
- Prepare to take next steps for program completion.
Medical Scribe Certification
CareerStep’s online Medical Scribe training covers the knowledge and skills you need to successfully sit for industry-recognized certification. We want to support our learners in securing the certification that fits based on your career goals and current job requirements. Your training includes an exam voucher and prep package for the CEHRS certification – a significant value add of several hundred dollars.
Certified Electronic Health Records Specialist (CEHRS)
Demonstrate you have the Electronic Health Record skills with the CEHRS from National Healthcareer Association.
Documents
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