The Complete Medical Scribe
A Guide to Accurate Documentation
- 3rd Edition - November 16, 2021
- Imprint: Elsevier
- Author: ABC Scribes, LTD
- Language: English
- Paperback ISBN:9 7 8 - 0 - 3 2 3 - 8 1 2 6 5 - 8
- eBook ISBN:9 7 8 - 0 - 3 2 3 - 8 1 2 5 4 - 2
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 Docum… Read more
Purchase options
Institutional subscription on ScienceDirect
Request a sales quoteExpand 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.
- Case studies with questions test your comprehension and let you apply your knowledge to the clinical setting.
- Review questions and exercises within chapters and online provide opportunities for self-quizzing to identify areas of strength and areas of focus.
- 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).
- Detailed instructional videos online simulate medical practice, using real doctor-patient encounters that progress logically through each part of the EHR.
- Notes boxes emphasize practice dos and don’ts along with on-the-job realities.
Medical Assisting Students
• 145,000+ estimated annual enrollment*- Cover image
- Title page
- Table of Contents
- Evolve Student Resources
- Copyright
- About the Authors
- Dedication
- Acknowledgments
- Preface
- Part I: The Medical Scribe in Healthcare
- Chapter 1. Healthcare Providers and the Role of the Medical Scribe
- Key Terms
- Providers and the Practice of Medicine
- The Medical Scribe
- Others Performing the Role of the Scribe
- Practice Questions
- Chapter 2. Healthcare Law and Ethics
- Key Terms
- Healthcare Documentation and Compliance
- Types of Law
- Consent
- Privacy and Confidentiality
- Fraud and Abuse
- Other Federal Legislation for the Medical Scribe
- Ethics
- Practice Questions
- Chapter 3. Scribe Safety and Infection Control
- Key Terms
- Scribe Safety
- Infection Control
- Practice Questions
- Part II: Health Record Documentation
- Chapter 4. The Health Record and Notes
- Key Terms
- Health Documentation and its Uses
- The Electronic Health Record (EHR)
- Health Record Components
- Medical Coding
- Practice Questions
- Chapter 5. Anatomy of a Provider Note
- Key Terms
- The History and Physical (H&P)
- Precharting
- Forms, Templates, Macros, and Cloning
- Chief Complaint
- History of the Present Illness (HPI)
- Review of Systems (ROS)
- Additional History
- Physical Exam (PE)
- Medical Decision Making (MDM)
- Time
- Practice Questions
- Chapter 6. Synthesis of a Patient History of Present Illness
- Key Terms
- Historians and Limitations
- Language
- Building Blocks
- Practice Questions
- Chapter 7. Documenting Diagnostic Tests and Therapeutic Procedures
- Key Terms
- Electrocardiogram (ECG) Notes
- Procedure Notes
- Practice Questions
- Chapter 8. Orders and Disposition Documentation
- Key Terms
- Orders
- Prescriptions
- Laboratory Orders
- Imaging
- Other Tests
- Orders for Healthcare Workers
- Order Panels
- Dispositions
- Practice Questions
- Chapter 9. Medical Terminology and Abbreviations
- Key Terms
- Medical Terminology
- Abbreviations
- Practice Questions
- Part III: Body Systems for the Medical Scribe
- Chapter 10. Constitutional
- Key Terms
- Anatomy and Physiology
- Review of Systems
- Physical Exam
- Practice Questions
- Chapter 11. Integumentary System
- Key Terms
- Anatomy and Physiology
- Review of Systems
- Physical Exam
- Operations/Procedures
- Problem List
- Practice Questions
- Chapter 12. Musculoskeletal System
- Key Terms
- Anatomy and Physiology
- Review of Systems
- Physical Exam
- Operations / Procedures
- Problem List
- Medications
- Practice Questions
- Chapter 13. HEENT (Head, Eyes, Ears, Nose, Throat)
- Key Terms
- Anatomy and Physiology
- Review of Systems
- Physical Exam
- Operations/Procedures
- Problem List
- Medications
- Practice Questions
- Chapter 14. Nervous System
- Key Terms
- Anatomy and Physiology
- Review of Systems
- Physical Exam
- Psychiatric Signs
- Operations/Procedures
- Problem List
- Medications
- Practice Questions
- Chapter 15. Cardiovascular System
- Key Terms
- Anatomy and Physiology
- Review of Systems
- Physical Exam
- Operations/Procedures
- Problem List
- Medications
- Practice Questions
- Chapter 16. Respiratory System
- Key Terms
- Anatomy and Physiology
- Review of Systems
- Physical Exam
- Operations/Procedures
- Problem List
- Medications
- Practice Questions
- Chapter 17. Gastrointestinal System
- Key Terms
- Anatomy and Physiology
- Review of Systems
- Physical Exam
- Operations/Procedures
- Problem List
- Medications
- Practice Questions
- Chapter 18. Genitourinary (Reproductive System and Urinary System)
- Key Terms
- Anatomy and Physiology
- Review of Systems
- Physical Exam
- Operations/Procedures
- Problem List
- Medications
- Practice Questions
- Chapter 19. Hematology and the Lymphatic and Immune System
- Key Terms
- Anatomy and Physiology
- Review of Systems
- Physical Exam
- Operations/Procedures
- Problem List
- Medications
- Practice Questions
- Chapter 20. Endocrine System
- Key Terms
- Anatomy and Physiology
- Review of Systems
- Physical Exam
- Operations/Procedures
- Problem List
- Medications
- Practice Questions
- Part IV: Practical Application
- Chapter 21. Anticipating Pertinent Questions for Chief Complaints
- Abdominal Pain
- Back Pain
- Chest Pain
- Eye Complaints
- Fall
- Headache
- Pregnancy Complications
- Shortness of Breath
- Trauma
- Weakness
- Practice Questions
- Chapter 22. Practice Exercises
- Case 1
- Case 2
- Case 3
- Case 4
- Case 5
- Case 6
- Key Points
- Answers to Case Studies and Practice Questions
- Chapter 1
- Chapter 2
- Chapter 3
- Chapter 4
- Chapter 5
- Chapter 6
- Chapter 7
- Chapter 8
- Chapter 9
- Chapter 10
- Chapter 11
- Chapter 12
- Chapter 13
- Chapter 14
- Chapter 15
- Chapter 16
- Chapter 17
- Chapter 18
- Chapter 19
- Chapter 20
- Chapter 21
- Glossary
- Index
- Edition: 3
- Published: November 16, 2021
- Imprint: Elsevier
- No. of pages: 432
- Language: English
- Paperback ISBN: 9780323812658
- eBook ISBN: 9780323812542
A
ABC Scribes, LTD
Dr. Kim Kwiatek, MD, FACEP, is president and founder of ABC Scribes, an Ohio-based company dedicated to the identification, training, and placement of medical scribes. Dr. Kwiatek is an emergency room physician and has practiced within the Kettering Health Network for nearly 40 years. Dr. Kwiatek has teamed up with a former medical student, Dr. Kaitlin Flamm, to write a comprehensive training guide that has been a foundational part of the ABC Scribes training program.