The Complete Medical Scribe
A Guide to Accurate Documentation
The concise handbook you need to be a great medical scribe
9780323812658, Elsevier Health Sciences
Paperback / softback, published 20 January 2022
432 pages
28.1 x 22.2 x 2.7 cm, 0.54 kg
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.
- 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.
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Case studies with questions test your comprehension and let you apply your knowledge to the clinical setting.
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Review questions and exercises within chapters and online provide opportunities for self-quizzing to identify areas of strength and areas of focus.
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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).
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Detailed instructional videos online simulate medical practice, using real doctor-patient encounters that progress logically through each part of the EHR.
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Notes boxes emphasize practice dos and don’ts along with on-the-job realities.
- 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
Subject Areas: Nursing & ancillary services [MQ]
