MTR-158 - Introduction to Medical Scribe

Lecture: 2

Lab: 6

OJT: 8

Credit: 7

This course is designed to prepare students to create a patient care record under the direct supervision of a physician. Students will learn to recognize and obtain a chief complaint, history of present illness, past medical, social and family histories, review of systems and physical exam. Medical procedures, lab results and other pertinent patient information for a patient visit will also be covered. Practical experience will include transcription/editing of history and physical reports, consultation reports, SOAP notes, progress notes and office notes. Students will obtain knowledge in classification of drugs, normal routes of administration, usage, and generic and brand names. Routine patient encounters, management of chronic diseases and characteristics of disease processes will be discussed. Students will identify the importance and challenges of medical documentation, including guidelines for evaluation and management of visits.