he final project for this course is a medical scribe portfolio in which you assume the role of a medical scribe and comple

1

HCM 205 Final Project Guidelines and Rubric

Overview Medical terminology refers to medical terms that are used in the art and science of medicine. It is a specialized language that originates as far back as 460 to 377 B.C. during the era of Hippocrates (Rice, 2015). Medical language is used to describe human body components, processes, conditions, and procedures. In the healthcare industry, medical terminology is the standardized method of communication for all healthcare professionals (Banova, 2013). In a clinical environment, understanding medical terminology makes communication, interpretation, and documentation of patient information faster and easier. As a HIM professional, this skill allows for increased efficiencies with organizing, reporting, and analyzing healthcare information, as well as billing for patient services. It is therefore essential for healthcare professionals to be fluent in medical terminology to ease clinical proceedings and more efficiently and effectively facilitate patient treatment (Banova, 2013). For your final project, through a realistic approach, you will assume the role of a Medical Scribe for a healthcare facility to complete a Medical Scribe Portfolio. A Medical Scribe is an individual trained in medical documentation who assists a physician throughout the workday (Medical Scribe-The Job Description, 2015). More specifically, the primary goal of a Medical Scribe is to assist the physician in increasing efficiency and productivity, and allowing the physician to focus full attention on the patient (Medical Scribe-The Job Description, 2015). In the final project, you will complete a series of tasks that you would likely perform daily as a medical scribe, and document these tasks in the Final Project Portfolio Template. Your first assignment is to assist the physician in documenting notes from a patient’s medical record. Second, you will review medical documents for accuracy in spelling, interpretation, and diagnosis. Your third and final assignment is to review patient records and use this information to educate the patient about his/her medical records and diagnosis. Throughout your project, you will use a recording tool, such as Vocaroo, to record your pronunciation of the medical terms. The preferred format is to utilize Vocaroo, but if you use an alternate method, upload a separate file with the recording. These activities are designed to guide you in the application of medical terminology as it relates to the clinical world. The final product will be submitted in Module Eight.

References Banova, B. (2013, March 20). The Language of Healthcare: Learning Medical Terminology. Retrieved from American Institute of Medical Sciences & Education:

https://www.aimseducation.edu/blog/the-language-of-healthcare-learning-medical-terminology/ Medical Scribe-The Job Description. (2015). Retrieved from American Healthcare Documentation Professionals Group:

https://www.ahdpg.com/medical-scribe-the-job-description/ Rice, J. (2015). Medical Terminology for Health Care Professionals. Upper Saddle River, NJ: Pearson. In this assignment, you will demonstrate your mastery of the following course outcomes:

2

● HCM-205-01: Apply medical terminology to body systems and medical specialties for documenting patient information [BS.HIT.CORE.01]

● HCM-205-02: Interpret medical records and reports for translating key patient information [BS.HIT.CORE.01]

● HCM-205-03: Communicate medical terminology by using accurate spelling and effective pronunciation [BS.HIT.CORE.01]

Prompt For your final project, you will assume the role of a medical scribe in a healthcare organization. You will complete a series of tasks that a medical scribe would complete in the field on a daily basis, and document these tasks in the Final Project Portfolio Template. You will submit your completed template to your instructor. To begin, you will assist a physician in documenting notes from a patient record by building medical terms, ensuring the terms are spelled correctly. You will also provide a recording of the pronunciation of the terms. Second, you will review medical documentation in a patient record to ensure accuracy. You will identify inaccuracies of spelling and interpretation, and provide the accurate spelling and revised SOAP note. For your third task, you will gather information to be used by the physician to educate a patient on their diagnosis. You will interpret the medical record to identify key terms, and then break down, define, and pronounce these terms. Note that these terms will all be constructed terms. To complete your task, you will provide a final summary of the diagnosis. For support on using Vocaroo, refer to the Vocaroo Tutorial. Specifically, the following critical elements must be addressed:

I. Documenting Patient Information: To begin your day, a physician has asked you to assist in documenting his notes from Patient Record One. The

physician has bolded the words or phrases that need interpreting in the Progress Notes. Based on these notes, build the medical terms that are

described, and add these to the Final Project Portfolio Template, making sure that each term is spelled correctly. Then, using a recording tool, such as

Vocaroo, record the medical terms. Add your recording to the Final Project Portfolio Template.

A. Build medical terms by using the appropriate word parts.

B. Be sure that the medical terms are spelled accurately.

C. Provide the effective pronunciation of the medical terms.

II. Reviewing Records for Accuracy: In the second part of your day, you will review medical documentation to ensure all information is accurate. Your task

is to review the SOAP note in Patient Record Two to ensure all medical terms are spelled correctly, and that the interpretation of the notes are accurate,

based on the patient’s diagnosis and result of relevant vitals. Document your review of the record in the Final Project Portfolio Template.

A. Identify the medical terms that are spelled incorrectly in the note.

B. Provide the accurate spelling for the medical terms.

3

C. Identify inaccuracies of interpretation in the SOAP note, and explain why the elements you identified are inaccurate.

D. Explain how to revise the SOAP note to include the correct medical terms and an accurate documentation of the patient’s diagnosis.

III. Interpreting Patient Information: To end your day, a physician has asked you to gather information she can use to educate a patient on how to interpret

their medical record and diagnosis. She has asked you to focus specifically on the History & Physical exam section of Patient Record Three, and the list of

medical terms she has compiled from the record. This list is located in the Final Project Portfolio Template. Note that each term the physician has listed

is a constructed term. Be sure to include a recording of the pronunciation of the medical terms in your Final Project Portfolio Template, using a tool such

as Vocaroo.

A. Break the medical terms into their word parts, and define each word part.

B. Define each medical term. Note: you previously defined the word parts, but now you will define each medical term as a whole.

C. Provide the effective pronunciation of the medical terms.

D. Explain the guidelines for building medical terms, providing specific examples using the terms from the patient record.

E. Provide a summary for the patient that clearly and succinctly describes the patient’s diagnosis detailed in the medical record.

Final Project Rubric

Guidelines for Submission: Submit the completed Final Project Portfolio Template to your instructor. Be sure to include files of your recordings of the pronunciation of medical terms, using a tool such as Vocaroo.

Critical Elements Exemplary Proficient Needs Improvement Not Evident Value

Documenting Patient Information: Build

Terms

N/A

(100%)

Builds medical terms by using the appropriate word parts (100%)

Builds medical terms, but does not use appropriate word parts for all medical terms (70%)

Does not build medical terms (0%)

11.2

Documenting Patient Information: Spelled

N/A

(100%)

Spells medical terms accurately (100%)

Spells medical terms with some inaccuracies (70%)

Does not spell medical terms accurately (0%)

5.5

Documenting Patient Information:

Pronunciation

N/A

(100%)

Provides the effective pronunciation of the medical terms (100%)

Provides the pronunciation of the medical terms, but with gaps in effectiveness or accuracy (70%)

Does not provide the effective pronunciation of the medical terms (0%)

5.6

4

Reviewing Records for Accuracy: Spelled

Incorrectly

N/A

(100%)

Identifies the medical terms that are spelled incorrectly in the note (100%)

Identifies medical terms that are spelled incorrectly in the note, but does not identify all terms, or has gaps in accuracy (70%)

Does not identify the medical terms that are spelled incorrectly in the note (0%)

5.5

Reviewing Records for Accuracy: Accurate

Spelling

N/A

(100%)

Spells identified terms accurately (100%)

Spells identified terms, but with inaccuracies (70%)

Does not spell identified terms accurately (0%)

5.5

Reviewing Records for Accuracy: Inaccuracies

of Interpretation

Meets “Proficient” criteria and explanation shows a sophisticated ability to interpret medical records

(100%)

Identifies inaccuracies of interpretation in the SOAP note, explaining why the identified elements are inaccurate (100%)

Identifies inaccuracies of interpretation in the SOAP note, explaining why the identified elements are inaccurate, but response has gaps in detail, logic, or accuracy (70%)

Does not identify inaccuracies of interpretation in the SOAP note (0%)

11.1

Reviewing Records for Accuracy: Revise Note

N/A

(100%)

Explains how to revise the SOAP note to include the correct medical terms and an accurate documentation of the patient’s diagnosis (100%)

Explains how to revise the SOAP note to include medical terms and documentation of the patient’s diagnosis, but with gaps in accuracy (70%)

Does not explain how to revise the SOAP note to include the correct medical terms and an accurate documentation of the patient’s diagnosis (0%)

11.1

Interpreting Patient Information: Word

Parts

N/A

(100%)

Breaks the medical terms into their word parts, defining each word part (100%)

Breaks the medical terms into their word parts, defining each word part, but does not define all terms, or has gaps in accuracy (70%)

Does not break the medical terms into their word parts, defining each word part (0%)

11.1

Interpreting Patient Information: Define

N/A

(100%)

Defines constructed medical terms (100%)

Defines constructed medical terms, but with gaps in clarity or accuracy (70%)

Does not define constructed medical terms (0%)

11.1

5

Interpreting Patient Information:

Pronunciation

N/A

(100%)

Provides the effective pronunciation of the medical terms (100%)

Provides the pronunciation of the medical terms, but with gaps in effectiveness or accuracy (70%)

Does not provide the effective pronunciation of the medical terms (0%)

5.6

Interpreting Patient Information: Guidelines

Meets “Proficient” criteria and examples provided demonstrate a sophisticated awareness of how to apply guidelines for building medical terms

(100%)

Explains the guidelines for building medical terms, providing specific examples using the terms from the patient record (100%)

Explains the guidelines for building medical terms, but with gaps in accuracy or support (70%)

Does not explain the guidelines for building medical terms (0%)

11.1

Interpreting Patient Information: Summary

Diagnosis

Meets “Proficient” criteria and summary shows a sophisticated ability to condense medical information into consumable terms

(100%)

Provides a summary for the patient that clearly and succinctly describes the patient’s diagnosis detailed in the medical record (100%)

Provides a summary for the patient that describes the patient’s diagnosis detailed in the medical record, but is verbose, or has gaps in clarity or accuracy (70%)

Does not provide a summary for the patient that describes the patient’s diagnosis detailed in the medical record (0%)

5.6

Total 100%

1

HCM 205 Final Project Guidelines and Rubric

Overview Medical terminology refers to medical terms that are used in the art and science of medicine. It is a specialized language that originates as far back as 460 to 377 B.C. during the era of Hippocrates (Rice, 2015). Medical language is used to describe human body components, processes, conditions, and procedures. In the healthcare industry, medical terminology is the standardized method of communication for all healthcare professionals (Banova, 2013). In a clinical environment, understanding medical terminology makes communication, interpretation, and documentation of patient information faster and easier. As a HIM professional, this skill allows for increased efficiencies with organizing, reporting, and analyzing healthcare information, as well as billing for patient services. It is therefore essential for healthcare professionals to be fluent in medical terminology to ease clinical proceedings and more efficiently and effectively facilitate patient treatment (Banova, 2013). For your final project, through a realistic approach, you will assume the role of a Medical Scribe for a healthcare facility to complete a Medical Scribe Portfolio. A Medical Scribe is an individual trained in medical documentation who assists a physician throughout the workday (Medical Scribe-The Job Description, 2015). More specifically, the primary goal of a Medical Scribe is to assist the physician in increasing efficiency and productivity, and allowing the physician to focus full attention on the patient (Medical Scribe-The Job Description, 2015). In the final project, you will complete a series of tasks that you would likely perform daily as a medical scribe, and document these tasks in the Final Project Portfolio Template. Your first assignment is to assist the physician in documenting notes from a patient’s medical record. Second, you will review medical documents for accuracy in spelling, interpretation, and diagnosis. Your third and final assignment is to review patient records and use this information to educate the patient about his/her medical records and diagnosis. Throughout your project, you will use a recording tool, such as Vocaroo, to record your pronunciation of the medical terms. The preferred format is to utilize Vocaroo, but if you use an alternate method, upload a separate file with the recording. These activities are designed to guide you in the application of medical terminology as it relates to the clinical world. The final product will be submitted in Module Eight.

References Banova, B. (2013, March 20). The Language of Healthcare: Learning Medical Terminology. Retrieved from American Institute of Medical Sciences & Education:

https://www.aimseducation.edu/blog/the-language-of-healthcare-learning-medical-terminology/ Medical Scribe-The Job Description. (2015). Retrieved from American Healthcare Documentation Professionals Group:

https://www.ahdpg.com/medical-scribe-the-job-description/ Rice, J. (2015). Medical Terminology for Health Care Professionals. Upper Saddle River, NJ: Pearson. In this assignment, you will demonstrate your mastery of the following course outcomes:

2

● HCM-205-01: Apply medical terminology to body systems and medical specialties for documenting patient information [BS.HIT.CORE.01]

● HCM-205-02: Interpret medical records and reports for translating key patient information [BS.HIT.CORE.01]

● HCM-205-03: Communicate medical terminology by using accurate spelling and effective pronunciation [BS.HIT.CORE.01]

Prompt For your final project, you will assume the role of a medical scribe in a healthcare organization. You will complete a series of tasks that a medical scribe would complete in the field on a daily basis, and document these tasks in the Final Project Portfolio Template. You will submit your completed template to your instructor. To begin, you will assist a physician in documenting notes from a patient record by building medical terms, ensuring the terms are spelled correctly. You will also provide a recording of the pronunciation of the terms. Second, you will review medical documentation in a patient record to ensure accuracy. You will identify inaccuracies of spelling and interpretation, and provide the accurate spelling and revised SOAP note. For your third task, you will gather information to be used by the physician to educate a patient on their diagnosis. You will interpret the medical record to identify key terms, and then break down, define, and pronounce these terms. Note that these terms will all be constructed terms. To complete your task, you will provide a final summary of the diagnosis. For support on using Vocaroo, refer to the Vocaroo Tutorial. Specifically, the following critical elements must be addressed:

I. Documenting Patient Information: To begin your day, a physician has asked you to assist in documenting his notes from Patient Record One. The

physician has bolded the words or phrases that need interpreting in the Progress Notes. Based on these notes, build the medical terms that are

described, and add these to the Final Project Portfolio Template, making sure that each term is spelled correctly. Then, using a recording tool, such as

Vocaroo, record the medical terms. Add your recording to the Final Project Portfolio Template.

A. Build medical terms by using the appropriate word parts.

B. Be sure that the medical terms are spelled accurately.

C. Provide the effective pronunciation of the medical terms.

II. Reviewing Records for Accuracy: In the second part of your day, you will review medical documentation to ensure all information is accurate. Your task

is to review the SOAP note in Patient Record Two to ensure all medical terms are spelled correctly, and that the interpretation of the notes are accurate,

based on the patient’s diagnosis and result of relevant vitals. Document your review of the record in the Final Project Portfolio Template.

A. Identify the medical terms that are spelled incorrectly in the note.

B. Provide the accurate spelling for the medical terms.

3

C. Identify inaccuracies of interpretation in the SOAP note, and explain why the elements you identified are inaccurate.

D. Explain how to revise the SOAP note to include the correct medical terms and an accurate documentation of the patient’s diagnosis.

III. Interpreting Patient Information: To end your day, a physician has asked you to gather information she can use to educate a patient on how to interpret

their medical record and diagnosis. She has asked you to focus specifically on the History & Physical exam section of Patient Record Three, and the list of

medical terms she has compiled from the record. This list is located in the Final Project Portfolio Template. Note that each term the physician has listed

is a constructed term. Be sure to include a recording of the pronunciation of the medical terms in your Final Project Portfolio Template, using a tool such

as Vocaroo.

A. Break the medical terms into their word parts, and define each word part.

B. Define each medical term. Note: you previously defined the word parts, but now you will define each medical term as a whole.

C. Provide the effective pronunciation of the medical terms.

D. Explain the guidelines for building medical terms, providing specific examples using the terms from the patient record.

E. Provide a summary for the patient that clearly and succinctly describes the patient’s diagnosis detailed in the medical record.

Final Project Rubric

Guidelines for Submission: Submit the completed Final Project Portfolio Template to your instructor. Be sure to include files of your recordings of the pronunciation of medical terms, using a tool such as Vocaroo.

Critical Elements Exemplary Proficient Needs Improvement Not Evident Value

Documenting Patient Information: Build

Terms

N/A

(100%)

Builds medical terms by using the appropriate word parts (100%)

Builds medical terms, but does not use appropriate word parts for all medical terms (70%)

Does not build medical terms (0%)

11.2

Documenting Patient Information: Spelled

N/A

(100%)

Spells medical terms accurately (100%)

Spells medical terms with some inaccuracies (70%)

Does not spell medical terms accurately (0%)

5.5

Documenting Patient Information:

Pronunciation

N/A

(100%)

Provides the effective pronunciation of the medical terms (100%)

Provides the pronunciation of the medical terms, but with gaps in effectiveness or accuracy (70%)

Does not provide the effective pronunciation of the medical terms (0%)

5.6

4

Reviewing Records for Accuracy: Spelled

Incorrectly

N/A

(100%)

Identifies the medical terms that are spelled incorrectly in the note (100%)

Identifies medical terms that are spelled incorrectly in the note, but does not identify all terms, or has gaps in accuracy (70%)

Does not identify the medical terms that are spelled incorrectly in the note (0%)

5.5

Reviewing Records for Accuracy: Accurate

Spelling

N/A

(100%)

Spells identified terms accurately (100%)

Spells identified terms, but with inaccuracies (70%)

Does not spell identified terms accurately (0%)

5.5

Reviewing Records for Accuracy: Inaccuracies

of Interpretation

Meets “Proficient” criteria and explanation shows a sophisticated ability to interpret medical records

(100%)

Identifies inaccuracies of interpretation in the SOAP note, explaining why the identified elements are inaccurate (100%)

Identifies inaccuracies of interpretation in the SOAP note, explaining why the identified elements are inaccurate, but response has gaps in detail, logic, or accuracy (70%)

Does not identify inaccuracies of interpretation in the SOAP note (0%)

11.1

Reviewing Records for Accuracy: Revise Note

N/A

(100%)

Explains how to revise the SOAP note to include the correct medical terms and an accurate documentation of the patient’s diagnosis (100%)

Explains how to revise the SOAP note to include medical terms and documentation of the patient’s diagnosis, but with gaps in accuracy (70%)

Does not explain how to revise the SOAP note to include the correct medical terms and an accurate documentation of the patient’s diagnosis (0%)

11.1

Interpreting Patient Information: Word

Parts

N/A

(100%)

Breaks the medical terms into their word parts, defining each word part (100%)

Breaks the medical terms into their word parts, defining each word part, but does not define all terms, or has gaps in accuracy (70%)

Does not break the medical terms into their word parts, defining each word part (0%)

11.1

Interpreting Patient Information: Define

N/A

(100%)

Defines constructed medical terms (100%)

Defines constructed medical terms, but with gaps in clarity or accuracy (70%)

Does not define constructed medical terms (0%)

11.1

5

Interpreting Patient Information:

Pronunciation

N/A

(100%)

Provides the effective pronunciation of the medical terms (100%)

Provides the pronunciation of the medical terms, but with gaps in effectiveness or accuracy (70%)

Does not provide the effective pronunciation of the medical terms (0%)

5.6

Interpreting Patient Information: Guidelines

Meets “Proficient” criteria and examples provided demonstrate a sophisticated awareness of how to apply guidelines for building medical terms

(100%)

Explains the guidelines for building medical terms, providing specific examples using the terms from the patient record (100%)

Explains the guidelines for building medical terms, but with gaps in accuracy or support (70%)

Does not explain the guidelines for building medical terms (0%)

11.1

Interpreting Patient Information: Summary

Diagnosis

Meets “Proficient” criteria and summary shows a sophisticated ability to condense medical information into consumable terms

(100%)

Provides a summary for the patient that clearly and succinctly describes the patient’s diagnosis detailed in the medical record (100%)

Provides a summary for the patient that describes the patient’s diagnosis detailed in the medical record, but is verbose, or has gaps in clarity or accuracy (70%)

Does not provide a summary for the patient that describes the patient’s diagnosis detailed in the medical record (0%)

5.6

Total 100%

Permission to reuse granted by Alfred State College and Michelle A. Green

Global Care Medical Center 100 Main St, Alfred NY 14802 (607) 555-1234 Hospital No. 999

INPATIENT FACE SHEET

Patient Name and Address Gender Race Marital Status Patient No.

LONG, BETH 4983 REED STREET ALMOND, NY 14804

F W M IPCase001 Date of Birth Age Maiden

Name Occupation

12/17/YYYY 30 Short Clerk

Admission Date Time Discharge Date Time Length of Stay Telephone Number

04/26/YYYY 1350 04/30/YYYY 1150 04 DAYS (607)555-3319 Guarantor Name and Address Next Of Kin Name and Address

LONG, BERNIE 4983 REED STREET ALMOND, NY 14804

LONG, BERNIE 4983 REED STREET ALMOND, NY 14804

Guarantor Telephone No. Relationship to Patient Next of Kin Telephone Number Relationship to Patient

(607)555-3319 Husband (607)555-3319 Husband Admitting Physician Service Admit Type Room Number/Bed

John Black, MD 369 Attending Physician Admitting Diagnosis

John Black, MD Fever of undetermined origin Primary Insurer Policy and Group Number Secondary Insurer Policy and Group Number

Diagnoses and Procedures ICD Code Principal Diagnosis

Acute Pyelonephritis

Secondary Diagnoses

Dehydration

Principal Procedure

Secondary Procedures

Discharge Instructions Activity:  Bed rest  Light  Usual  Unlimited  Other: Diet:  Regular  Low Cholesterol  Low Salt  ADA  _____ Calorie

Follow-Up:  Call for appointment  Office appointment on  Other: To be seen for a follow up in office in one week

Special Instructions: None Attending Physician Authentication: Reviewed and Approved: John Black MD

ATP-B-S:02:1001261385: John Black MD (Signed: 4/30/YYYY 2:20:44 PM EST)

Permission to reuse granted by Alfred State College and Michelle A. Green

LONG, BETH

IPCase001

Dr. BLACK

Admission:04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

CONSENT TO ADMISSION

I, Beth Long hereby consent to admission to the Global Care Medical Center (ASMC) , and I further consent to such routine hospital care, diagnostic procedures, and medical treatment that the medical and professional staff of ASMC may deem necessary or advisable. I authorize the use of medical information obtained about me as specified above and the disclosure of such information to my referring physician(s). This form has been fully explained to me, and I understand its contents. I further understand that no guarantees have been made to me as to the results of treatments or examinations done at the ASMC.

Reviewed and Approved: Beth Long ATP-B-S:02:1001261385: Beth Long (Signed: 4/26/YYYY 2:12:05 PM EST)

Signature of Patient

Signature of Parent/Legal Guardian for Minor

Relationship to Minor Reviewed and Approved: Andrea Witteman ATP-B-S:02:1001261385: Andrea Witteman (Signed: 4/26/YYYY 2:12:05 PM EST

WITNESS: Global Care Medical Center Staff Member

CONSENT TO RELEASE INFORMATION FOR REIMBURSEMENT PURPOSES In order to permit reimbursement, upon request, the Global Care Medical Center (ASMC) may disclose such treatment information pertaining to my hospitalization to any corporation, organization, or agent thereof, which is, or may be liable under contract to the ASMC or to me, or to any of my family members or other person, for payment of all or part of the ASMC’s charges for services rendered to me (e.g. the patient’s health insurance carrier). I understand that the purpose of any release of information is to facilitate reimbursement for services rendered. In addition, in the event that my health insurance program includes utilization review of services provided during this admission, I authorize ASMC to release information as is necessary to permit the review. This authorization will expire once the reimbursement for services rendered is complete.

Reviewed and Approved: Beth Long ATP-B-S:02:1001261385: Beth Long (Signed: 4/26/YYYY 2:14:17 PM EST)

Signature of Patient

Signature of Parent/Legal Guardian for Minor

Relationship to Minor Reviewed and Approved: Andrea Witteman ATP-B-S:02:1001261385: Andrea Witteman (Signed: 4/26/YYYY 2:16:24 PM EST

WITNESS: Global Care Medical Center Staff Member

Permi

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