This course provides a foundation for the medical transcriptionist career field. The primary areas of study in this course include types of clinical documents, style guidelines, nomenclature, and measurement and numeration. Facility best practices and sample reports will also be explored.
Students will:
- Distinguish between a variety of clinical documents.
- Identify best practices in editing.
- Use correct punctuation, capitalization, and grammar in clinical documents.
- Identify style rules related to numerical values in the clinical record.
- Model proper use of style rules in a variety of medical specialties.
- Outline recommendations for writing policies and procedures related to standard text and templates.
This course prepares a student to go take the AHDI Registered Healthcare Documentation Specialist (RHDS) national certification exam.
Course Outline:
Lesson 1: The Clinical Record
In this introductory lesson, we will learn about the types of clinical records and the protocol for editing these records.
Lesson 2: Standards of Style
This lesson provides an overview of grammar and punctuation that is so vital to the clinical record. Topics include punctuation, capitalization, plurals, possessives, foreign terms, abbreviations, and symbols.
Lesson 3: Measurement and Quantitation
Numerical values are a critical part of the clinical record. Whether it is the patient’s age, vital signs, duration of symptoms, wound measurements, laboratory values, drug dosages, length of stay, indication of pain, or classification of disease, numbers must be communicated clearly and accurately in all areas of the record. Style rules related to numerical values in the clinical record are the focus of this lesson.
Lesson 4: Specialty Standards, part 1
In this lesson, we will learn the importance of using styles and standards in a variety of fields. In this lesson, we will focus on chemistry, pharmacology, cardiology, genetics, hematology, oncology, immunology, orthopedics, and neurology.
Lesson 5: Specialty Standards, part 2
We will continue the use of standards and styles in specialty areas. In this lesson, we will focus on obstetrics, gynecology, pediatrics, ophthalmology, microbiology, pulmonology, psychiatry, and other specialties.
Lesson 6: Facility Best Practices
In this last lesson, we will look at best practices in clinical documentation. We will explore the benefits of templates. tips on clinician documentation, policies regarding the use of technology, and how to use gender pronouns in documents.
All necessary course materials are included.
Certification(s):
This course prepares a student to go take the AHDI Registered Healthcare Documentation Specialist (RHDS) national certification exam.
