Medical   

Hardware Requirements:

• This course can be taken on either a PC, Mac, or Chromebook.

Software Requirements:

• PC: Windows 8 or later.
• Mac: macOS 10.6 or later.
• Browser: The latest version of Google Chrome or Mozilla Firefox are preferred. Microsoft Edge and Safari are also compatible.
• Adobe Acrobat Reader.
• Software must be installed and fully operational before the course begins.

Other:

• Email capabilities and access to a personal email account.

Instructional Material Requirements:

The instructional materials required for this course are included in enrollment and will be available online.

Prepare for a rewarding career as an important member of the physical therapy team. This course will teach you about the workings of the human body, various disorders, patient safety, and even how to speak the language of physical therapy.

Introduction to Physical Therapy

In this lesson, you'll be introduced to the profession of physical therapy (PT). You'll learn about the history of PT and how two wars and an epidemic created a need for this profession. To help you understand what makes PTs different from other health care professionals, this course will discuss the types of patients who need PT and the types of treatment PTs use. You'll understand the important difference between PTs, PT assistants, and PT aides as you come to understand the special role of PT aides.

Communication for the Physical Therapy Aide

As a PT aide, you'll communicate with many different people, so this lesson will focus on the communication skills you'll need to help you communicate with your supervising PT, patients, and their families. You'll learn about some of the challenges you'll face when communicating with sick or injured people, and how to demonstrate the traits of empathy, respect, and patience. You'll also spend some time on SOAP notes—the method many medical personnel use to document their evaluations and patient treatments.

Ethics and Law for the PT Aide

This very important lesson will help you stay out of trouble by discussing the law and ethics for the PT aide. You'll learn the differences between law and ethics and why you must be concerned about both. You'll go over the American Physical Therapy Association's Code of Ethics, relating its principles to PT aides. You'll also learn about the American Hospital Association's A Patient's Bill of Rights so you'll know how you should treat patients in different situations. You'll want to understand both negligence and malpractice, so this lesson covers those topics, too. Finally, you'll spend some time on the very important topic of patient confidentiality. You can face stiff penalties if you violate patient confidentiality, so you need to have a thorough understanding of this topic.

The Language of Physical Therapy

Have you ever noticed that every profession has its own unique language? The health care profession is no different. As a PT aide, it's vitally important that you understand the language that PTs use, which is the focus of this lesson. You'll cover planes of the body and directional terms. You'll also learn the terms that define the body's major regions and body cavities. The movements of joints have special names; this lesson will define them and include lots of graphics that demonstrate these movements. You'll finish up by learning some other terms related to function and movement in the last chapter.

Anatomy and Physiology: Part 1

In this lesson, you'll begin learning about the body's organ systems. You'll go over how your body is organized, from atoms to an entire individual. You'll learn about the muscular, skeletal, nervous, endocrine, circulatory, and lymphatic systems. You'll also learn about the organs in each of these systems, the jobs they perform, and disorders affecting these systems that are commonly treated by PTs.

Anatomy and Physiology: Part 2

In this lesson, you'll continue learning about the organ systems. To start out, you'll see how human organ systems are interrelated and how a problem with one system will affect the others. You'll then move on to a discussion of the integumentary (skin), digestive, urinary, respiratory, and reproductive systems. You'll learn about each system's organs, function, and some common disorders. You'll finish the lesson with a discussion of the most important concept in human physiology—homeostasis. Homeostasis means the drive of your body to keep many different variables, like blood pressure and temperature, within a certain range. You'll find out why this is so crucial and how you might be asked to monitor homeostasis while caring for patients.

Safety for the Physical Therapy Aide: Part 1

You'll start learning about specific safety issues in this lesson, focusing on infection control. Anyone working in healthcare must understand the meaning of infection, its causes, and how it spreads. To help you understand this, this lesson discusses the chain of infection and what you can do to break that chain so that the infection doesn't spread from one person to another. You'll spend some time on an infection called MRSA because it's so common and dangerous. Since proper hand hygiene is the most effective way to stop infection from spreading, you'll go over the Centers for Disease Control and Prevention's guidelines. You'll also learn about patient-care equipment, environmental control, and the role of vaccinations.

Safety for the Physical Therapy Aide: Part 2

You'll explore important safety issues again in this lesson, but this time, instead of infection, you'll focus on proper body mechanics and safe patient transfers. Body mechanics means the posture of your body and how you move it. You must understand proper body mechanics to protect yourself from injury. The lesson starts out with a discussion of the anatomy of the spine since the spine gets hurt most often when you ignore proper body mechanics. It talks about proper posture and the importance of paying attention to your center of gravity. It also goes over a list of principles for using proper body mechanics and guidelines for moving patients in a variety of different situations. You'll also learn about lifting machines, which PTs now commonly use to transfer patients.

Helping Patients Walk

Most people take walking for granted, but many patients must learn to walk again after an illness or injury. PTs often ask their aides to help with this, so you must understand what types of conditions make it hard for people to walk. You should also understand the normal gait cycle, so this lesson will spend some time on that topic and tell you about common deviations from normal gait. You'll also learn about different ambulatory devices, including parallel bars, walkers, crutches, and canes and how they're used in PT.

Using Physical Agents

PTs use physical agents, rather than medications or surgery, to treat patients. These agents include heat, cold, ultrasound, traction, and electricity. To explain these agents, you'll start by learning about the relationship between a disease or injury and one's ability to perform activities of daily living. You'll then follow a fictitious Mrs. Smith as she struggles to recover from a car accident. You'll learn about the physical agents her PT chooses and how they affect her body. You'll end by learning about contraindications (when an agent should never be used) and precautions (when an agent must be used with extra care).

Use of Exercise: Part 1

Along with physical agents, PTs use exercise to treat patients. In this lesson, you'll learn about three types of exercise—strength training, aerobic exercise, and range-of-motion exercise. You'll learn how muscles are put together and why resistance is necessary to build strength. This lesson will teach you about three important principles you should know when supervising a strength training program. You'll also go over aerobic exercise and learn how it increases a person's ability to use oxygen. Finally, you'll learn about range-of-motion exercises. You'll find out how PTs measure how far a patient can move a joint and why joints sometimes become limited in their motion. You'll learn about different types of range-of-motion exercises and important principles to follow.

Use of Exercise: Part 2

In the final lesson, you'll explore balance, coordination, and developmental delays. This lesson focuses on children, but the information will be helpful if you're treating adults, too. You'll learn about a special sensory system called the vestibular system and how important it is for maintaining balance. You'll view examples of activities PTs use to treat children with balance problems, and learn about the adaptive response—something PTs continually look for when treating children. The lesson will move on to a discussion of developmental coordination disorder, and you'll learn how important it is for professionals to properly diagnose this condition. Moving onto the subject of developmental delays, you'll learn about developmental milestones and how PTs treat children who fail to meet those milestones. You'll also see how PTs use developmental activities with adults who have sustained traumatic brain injuries.

What you will learn

• Learn about the human body, specific disorders, and how physical therapists can treat these disorders
• Learn about proper body mechanics and how to safely help patients with range of motion
• Explore the history of physical therapy and identify the various functions carried out by working physical therapists
• Acquire needed skills for communicating with sick or injured people, and learn how to demonstrate the traits of empathy, respect, and patience as a PT

How you will benefit

• Gain valuable communication skills and insights about the human body that are valuable in any line of work
• Attain the crucial knowledge and skills you will need to advance toward a rewarding career in physical therapy
• Discover strength training, aerobic exercises, and range-of-motion exercises that are personally beneficial to you and to those you love

Holly Trimble

Holly Trimble earned a bachelor's degree in Physical Therapy from the University of Colorado, a master's degree in Pediatric Physical Therapy from Boston University, a master's degree in Biology from the University of Nebraska at Kearney, and a doctoral degree in Physical Therapy from Arcadia University. After working as a physical therapist for many years, Dr. Trimble transitioned into teaching. She has lectured on health-related topics to all age groups and has taught middle and high school science courses in both private and public school settings. She currently teaches Anatomy and Physiology for a local community college system, where she has taught for the past 15 years. Holly received the Adjunct Faculty Excellence Award both of the years she was nominated and is the author of the eBook, "College Success Now!"

Requirements:

Hardware Requirements:

• This course can be taken on either a PC, Mac, or Chromebook.

Software Requirements:

• PC: Windows 8 or later.
• Mac: macOS 12 or later.
• Browser: The latest version of Google Chrome or Mozilla Firefox are preferred. Microsoft Edge and Safari are also compatible.
• Adobe Acrobat Reader.
• Software must be installed and fully operational before the course begins.

Other:

• Email capabilities and access to a personal email account.

Instructional Material Requirements:

The instructional materials required for this course are included in enrollment and will be available online.

Becoming a Clinical Medical Assistant

In this lesson, you'll discover the attributes, qualities, and job description of a medical assistant such as effective communication, knowledge, skill, good health and hygiene, empathy, integrity, a positive attitude, and ethical behavior. You'll explore a medical assistant's employment opportunities, which include a variety of healthcare facilities such as urgent care, outpatient clinics, laboratories, nursing facilities, and more. The lesson will also discuss a medical assistant's expected ethical behavior, scope of practice, and compliance with healthcare laws, including HIPAA (privacy and security laws).

Medical Documents, Reports, and the Medical Record

This lesson will take a closer look at the medical record and various medical documents and reports. Medical assistants are expected to document accurately and professionally in the medical record, so you will explore how the electronic signature works and why it's necessary on medical documents. The lesson will then discuss the electronic health record and the electronic medical record. You will also learn about progress notes and how they are the heart of the medical record.

Telecommunications, Enhancing the Patient Experience, and Professionalism Attributes

In this lesson, you will learn about the various types of communications in the medical office and how to deal with difficult patients. The lesson will discuss how the patient experience can influence the patient's perception of the medical assistant, the office, and the care received. You'll examine professional attributes such as being responsible, ethical, team-oriented, and to possess strong communication, interpersonal, and problem-solving skills. Today more than ever, employers are looking for employees with problem-solving skills and critical thinking capabilities.

Computers, Insurance, and Medical Billing and Coding

In this lesson, you'll learn the definitions of EMR (electronic medical record) and EHR (electronic health record) and find out why the terms aren't synonymous. You'll also learn more about the financial features of practice management software.

Major Body Systems and Pathophysiology

In this lesson, you will learn about pathophysiology and explore the 12 major body systems. You'll learn about common diseases and injuries that affect the human body.

The Chief Complaint and Patient History

This lesson will give you a comprehensive look at how to room the patient, record a proper chief complaint (CC), and collect the medical history of the patient (current, past, family, and social history) as related to your role as a clinical medical assistant. You'll learn about charting and how it can affect patients' care.

Recording Vital Signs

This lesson will discuss the importance of vital signs and measurements, and the name of the equipment used. You'll examine the procedures used to take the vital signs and body measurements of patients, which include body temperature, blood pressure, pulse (heart rate), respiratory rate, as well as body measurements such as height and weight.

The Physical Examination and the Laboratory Testing

This lesson will introduce you to the physical examination, specialty exams and procedures, and the medical laboratory. You'll explore the methods, examination positions, instruments, and supplies used by doctors to examine the body and the medical assistant's role in preparing the patient for specialty exams. This lesson will also discuss the purposes of laboratory testing, the different types of medical laboratories, and their quality standards.

Medical Asepsis, Infection Control, and Basic Microbiology

This lesson will discuss the steps in the infection cycle and about helpful and pathogenic (infectious) microorganisms. You will examine how to prevent transmission of infectious microorganisms and identify examples of personal protective equipment (PPE). The lesson will explain the importance of handwashing and the proper way to dispose of biohazard waste. Lastly, you will be introduced to the five areas of a microbiology lab.

Surgical Asepsis and Sterilization Techniques

In this lesson, you will learn about surgical asepsis and the different methods of sterilization such as autoclaving, chemical, gas, and dry heat. The lesson will discuss the importance of a surgical hand scrub in preventing healthcare-associated infections and how preparing the patient's skin with a prepping solution is a crucial step in preventing surgical site infections.

Basic Guidelines for Administration of Injections and Noninjectable Medications

This lesson will focus on the basic guidelines for the administration of injections and noninjectable medications. You will also examine how to safely administer injectable medications by discussing the parts of a needle, the gauge, how to select the proper needle, and how to determine the volume of medication. You will also learn about the types of medication containers, injection techniques, and administration of oral and inhaled medications. Lastly, this lesson will cover types of medication errors, reporting an error, and preparing an incident report.

Emergencies and First Aid in the Medical Office

In this lesson, you'll explore emergencies in the medical office and first aid. The lesson will discuss the four types of shock and description and cause of each type. You will learn how to recognize symptoms of shock and the procedures on how to treat them immediately. You will also learn about diabetic emergencies, how to recognize the symptoms of insulin shock and diabetic ketoacidosis, and about administering insulin injections. Lastly, this lesson will discuss emergencies and administering first aid for patients with open wounds, burns, and musculoskeletal injuries.

What you will learn

• Describe the job duties, skills, scope of practice, and values of a clinical medical assistant.
• Explain the information contained in different types of medical records.
• Recognize the importance of enhancing the patient experience.
• Summarize the main functions and common diseases of the 12 body systems.
• Explain the purpose of the chief complaint and identify the parts of a patient's medical history in a progress note.
• Discuss the importance of vital signs, and name the equipment used when measuring vital signs.
• Identify various methods, positions, and instruments used for examining a patient.
• Explain the importance of hand-washing and personal protective equipment in asepsis and infection control.
• List the basic guidelines for administering medications.
• Recognize emergencies in the ambulatory medical setting.

How you will benefit

• Learn if a career in healthcare is right for you and where you fit in
• Open the door to new career opportunities and discover a fulfilling career path

Meggen Leigh Green

Meggen Leigh Green is registered nurse who previously worked as clinical medical assistant for over 10 years at a large pediatric group. As a medical assistant, Meggen worked as both a clinical supervisor and team leader, overseeing all clinical staff training, ongoing education, evaluations, vaccine inventory, and laboratory certifications. She holds a Medical Assisting degree and ASN RN degree from Ivy Tech.

Requirements:

Hardware Requirements:

• This course can be taken on either a PC, Mac, or Chromebook.

Software Requirements:

• PC: Windows 8 or later.
• Mac: macOS 10.6 or later.
• Browser: The latest version of Google Chrome or Mozilla Firefox are preferred. Microsoft Edge and Safari are also compatible.
• Adobe Acrobat Reader.
• Software must be installed and fully operational before the course begins.

Other:

• Email capabilities and access to a personal email account.

Instructional Material Requirements:

The instructional materials required for this course are not included in enrollment.

• A CPT Manual, Professional Edition, and an ICD-10-CM Manual are required for this course.

Please note: Current manuals are not encouraged, but books published within the past five years work very well. It's not necessary to buy the books before the course starts. There is further guidance about books provided in the opening discussion board.

Explore a career as a medical coder and gain knowledge to help you work, with confidence, almost anywhere in the medical field from doctors' offices, clinics, hospitals, or even in the comfort of your home. This course teaches use of the CPT manual and IDC-10-CM which will give you a leg up on others who are new to this career.

Medical Coding Basics

The first lesson explores the history of medical insurance and medical coding. After that, take a few minutes to get familiar with the coding books and tools that medical coders use. This lesson finishes up with an important discussion about patient privacy and confidentiality.

Coding in the Real World

In this lesson, you'll take a close look at how medical professionals use medical codes in the real world. Get to know the common form medical coders use and explore the different types of medical codes you will find in your coding books. By the time you finish the lesson, you will understand how the different types of codes come together on a claim and how they tell the insurance company a complete story about any doctor-patient encounter.

Getting to Know Your CPT Manual

In this lesson, take a detailed tour through the CPT manual where you will find medical codes for the procedures and treatments doctors and other medical professionals provide their patients. You will learn all about the CPT symbols, modifiers, and unlisted procedures. By the end of this lesson, you will be looking up your first codes!

Getting to Know Your ICD-10-CM

Similar to the last lesson, you will take a detailed tour through the other coding book used in this course, the ICD-10-CM, which is where you will find the codes for any disease, illness, condition, or symptom that a patient may have. You will learn all about the ICD-10-CM's symbols, formatting, and other conventions; and you will learn where to find external cause codes and Z-codes. By the end of this lesson, you will begin to practice coding diagnoses.

Coding the Integumentary System

Starting with this lesson, you'll begin a series of lessons that take you in depth into one body system at a time, which will help you understand specific medical coding situations for each area of the human body. This lesson explores the integumentary (skin) system. You will review the code categories for the most common skin conditions, infections, injuries, and procedures, and then practice coding cases that involve common skin problems.

Coding the Musculoskeletal System

In this lesson, you will learn all about the musculoskeletal system and study some important musculoskeletal vocabulary. Review the code categories for the most common muscle and bone conditions and injuries and learn how to code the procedures doctors use to treat common problems.

Coding the Respiratory System

This lesson focuses on the respiratory system, and how to code the most common respiratory conditions and injuries. After that, you will practice coding the most common respiratory procedures that doctors use on their patients.

Coding the Cardiovascular System

In this lesson, you'll explore the cardiovascular system. You'll learn how to code common heart, vein, and artery conditions and diseases and how to code the procedures doctors use most often to treat these common diagnoses. As always, this lesson follows up on cardiovascular diseases and procedures with coding practice.

Coding the Digestive and Endocrine Systems

In this lesson, you will learn all about the digestive system and the endocrine system. Begin by studying some important vocabulary for both systems, and then review the code categories for the most common conditions, diseases, and injuries. After that, explore the procedures doctors perform to fix digestive and endocrine system problems.

Coding the Male and Female Genitourinary Systems

In the last of your system-specific lessons, you will review the male and female genitourinary systems; and learn how to code common conditions, diseases, and procedures for both systems. You will also spend time discussing maternity and childbirth and the special medical coding challenges you will need to consider in those cases.

Evaluation and Management (E/M) Codes

Ready to get to know Evaluation and Management codes? In this lesson, you will learn the three key components of any E/M service and discover some helpful charts you can use to narrow down an E/M code range to a final E/M code. And as you probably guessed, this lesson ends with plenty of E/M coding practice!

Surgical Packages and Modifiers

In the final lesson, you will find out what's included in a surgical package and what's not. You will also learn all about modifiers and find out why medical coders use them to let insurance companies know about special circumstances. Finally, you will put everything you've learned throughout the course together by coding some practice scenarios that incorporate all of the different types of codes!

What you will learn

• Learn how to use the CPT manual and the ICD-10-CM to find medical codes
• Discover the medical terminology, conditions, diseases, injuries, treatments, and procedures you'll see most often in each of the main systems of the human body
• Learn to come up with just the right codes to describe any medical situation

How you will benefit

• Get all the hands-on experience you'll need to code medical insurance claims with confidence
• Know how to find your way through both the CPT manual and the ICD-10-CM manual
• Begin your journey to a career as a medical coder

Jennifer Della'Zanna

Jennifer Della'Zanna has more than 20 years of experience in the healthcare industry, having worked as a medical transcriptionist, practice administrator, biller, and coding specialist. She writes courses and study guides on the use of technology in health care and regularly contributes to publications about health issues. Della'Zanna is a member of the American Academy of Professional Coders and the Association for Healthcare Documentation Integrity. She holds a Bachelor of Arts from Albright College.

Requirements:

Hardware Requirements:

• This course can be taken on either a PC, Mac, or Chromebook.

Software Requirements:

• PC: Windows 10 or later.
• Mac: macOS 10.6 or later.
• Browser: The latest version of Google Chrome or Mozilla Firefox are preferred. Microsoft Edge and Safari are also compatible.
• Adobe Acrobat Reader.
• Software must be installed and fully operational before the course begins.

Other:

• Email capabilities and access to a personal email account.

Instructional Material Requirements:

The instructional materials required for this course are included in enrollment and will be available online.

Healthcare documentation specialists used to be called medical transcriptionists, but the field has grown to include voice recognition editing and scribing duties. The expanded possibilities for employment and the upgraded skills are reflected in the new title. In this course, you will learn traditional transcription and the skills needed for voice recognition (VR) editing and scribing.

Introduction to Medical Transcription/Healthcare Documentation

In this first lesson, we'll look at the history of medical transcription as a career. You'll find out how the field has evolved from medical secretary to transcriptionist and into its modern form. You'll explore the various medical transcriptionist skills and aptitudes you'll need to succeed in the field. You'll examine the type of work HDSs produce, and we'll look at the kinds of jobs that exist today, where you might work, and what might be in store for those working in this field.

Tools of the Trade

We'll start by discussing the HDS's tools of the trade, reviewing a few of the reference books and the types of websites that HDSs use for research. Then, we'll look at the hardware and software used on the job. We'll talk you through downloading the free software we'll use in this course, and then we'll go through a quick tour of how to use it. By the end of this lesson, you'll be sitting at your computer, experiencing an actual medical dictation audio file, and using the Express Scribe software on your screen. As you work through the medical report, you'll practice starting, pausing, and rewinding the audio as you tap away on the keyboard.

Understanding Medical Records

There are nine report types that medical professionals use most often in both hospitals and clinics. In this lesson, we'll review various examples of real medical reports. We'll also do a quick review of medical correspondence. Medical letters aren't much different from traditional letters, but since you might not have typed a traditional letter in a while, a refresher might be nice. We'll finish the lesson with some specific tips about pathology reports and how to handle numbers and measurements. Then, you'll practice transcribing a medical letter and a pathology report.

Listening Carefully

We'll spend this lesson reviewing how to listen most effectively and discussing the difference between hearing and active listening. We'll also touch on many issues that keep voice recognition systems from replacing humans, including homonyms, synonyms, and antonyms. Then, we'll discuss how you can use phonetics and vowel sounds (as well as a few other tricks!) to help you figure out a word or phrase in a muddled recording. Then we'll talk a bit about the radiology department and radiology reports and finish by practicing transcribing one in today's assignment.

Grammar, Sentence Structure, and Punctuation

Lesson 5 will discuss subjects that might make you cringe a little: grammar, sentence structure, and punctuation. But this will be a painless, maybe even enjoyable, journey through some of the basic principles of writing that will help you become a better HDS. We will learn a little more about SOAP notes and then turn our attention to infectious diseases and medications. You'll also have the chance to transcribe a SOAP note and a radiology report in the lesson assignment.

Style

We'll continue our writing examination in this lesson by discussing style from the HDS perspective. Whether transcribing or editing a document produced by voice recognition, you must follow editorial directions in spelling, capitalization, and typographical display. Those directions are the style HDSs must be concerned about. You'll be surprised at how many different ways you can treat a single word. Should it be capitalized or lowercase? Should you abbreviate it, or should you spell it out? Should your numbers be in digit form or word form? These are the issues we will cover in this lesson. Finally, we'll focus on the H&P report, and you'll have the chance to practice transcribing one.

Medical Terminology and Spelling

No matter what you transcribe or edit, you can be sure that medical terminology will be a huge part of it. That's what we'll be focusing on today. Dictators aren't perfect. They might say one word when they actually mean another. Or they might say a word that has a sound-alike word, like anuresis and enuresis. If you understand medical terminology well, you can pinpoint the correct word to ensure your transcription is accurate. Then, we will review the basic nature of heart disease and its treatment. We'll also take a close look at another common disease: diabetes.

Report Formatting and Word Processing

A critical component of the HDS's work is how you put your reports together. So, we'll talk about how to break up your reports into sections with headings, subheadings, special line spacing, page breaks, and other formatting niceties. We'll also look closer at ways you can make your work easier by using word processing shortcuts, AutoText, macros, and templates. Mastering them will make you a faster and more efficient HDS! We will also focus on surgical reports. Surgical terminology is important to know, and it's also fascinating to take a look at what goes on in the operating room. The assignment for this lesson will include a surgical report to help you put to work all the new knowledge you've gained.

Checking Your Work

Another essential step in healthcare documentation is editing and proofreading your work; that's what we'll concentrate on today. We will start by sharing some editing do's and don'ts and what to look for when proofreading. We will cover a disease process that has affected virtually everyone in some way: cancer. Once you have an overview of cancer, we'll work on the consultation report. Physicians often ask specialists to evaluate their patients, especially cancer patients, further. So, this is a common report you'll likely transcribe regularly. The lesson assignment includes a consult report to transcribe, and you'll also get to practice proofreading.

Classification Systems, and Discharge and Death Summaries

So far, we've focused on the mechanical elements of medical transcription. But there is still a lot you need to know about clinical issues. So, this will be an entirely clinical lesson. We'll talk about classification systems and their transcription foibles. Plus, now that you have the bones of grammar and style down, we'll talk about some real bones. We'll begin by discussing fractures and spine levels. Finally, we'll discuss discharge and death summaries. They are very similar reports, but we'll examine some subtle differences.

Infections, Blood, and Cells

This lesson will be similar to the last in that it covers many clinical issues. It won't all be clinical, however. There are a few miscellaneous things to cover. They don't fit into neat categories, so they are all put here. Once we finish with these miscellaneous items, we'll jump back into some clinical issues, talking specifically about infections. Then, we'll focus on smaller components of the body: cells and blood. You'll notice how everything you've learned can come together in an autopsy report. This is probably the longest, most comprehensive report you'll come across. Of course, you'll also have the chance to transcribe an autopsy report in the assignment!

The Nuts and Bolts of Working as an MT

By now, you have the tools and the knowledge you need to dip your toe into the waters of healthcare documentation. But we still have a couple of big questions to answer. How do you manage your workload? Also, how do you establish yourself as a medical transcriptionist? And do you need more training? Today, we'll discuss the various ways you can work—everything from being an independent contractor all the way up to consultant work. We'll talk about additional training as well. Then, we'll take a peek at why this is an exciting time to enter the medical transcription field. We will look at some details about working in related fields, such as document integrity specialist, EHR specialist, and scribe.

What you will learn

• Explore how to work with digital tools to transcribe medical reports from audio dictation
• Apply techniques that will help you make decisions about editing reports produced by voice recognition
• Discuss major points of documentation for a variety of disease processes
• Compare skills needed for transcription, voice recognition editing, and scribe positions

How you will benefit

• Gain the knowledge needed to work in this growing field
• Possess the opportunity to practice skills that can be applied to any of the positions available to a healthcare documentation specialist
• Discover the state of the industry and where it may expand in the future
• Discuss and examine the importance of accurate medical record reporting to the health and safety of patients

Jennifer Della'Zanna

Jennifer Della'Zanna has more than 20 years of experience in the healthcare industry, having worked as a medical transcriptionist, practice administrator, biller, and coding specialist. She writes courses and study guides on the use of technology in health care and regularly contributes to publications about health issues. Della'Zanna is a member of the American Academy of Professional Coders and the Association for Healthcare Documentation Integrity. She holds a Bachelor of Arts from Albright College.

Hardware Requirements:

• This course can be taken on either a PC, Mac, or Chromebook.

Software Requirements:

• PC: Windows 8 or later.
• Mac: macOS 10.6 or later.
• Browser: The latest version of Google Chrome or Mozilla Firefox are preferred. Microsoft Edge and Safari are also compatible.
• Adobe Acrobat Reader.
• Software must be installed and fully operational before the course begins.

Other:

• Email capabilities and access to a personal email account.

Instructional Material Requirements:

The instructional materials required for this course are included in enrollment and will be available online.

Prepare for a rewarding career as an important member of the physical therapy team. This course will teach you about the workings of the human body, various disorders, patient safety, and even how to speak the language of physical therapy.

Introduction to Physical Therapy

In this lesson, you'll be introduced to the profession of physical therapy (PT). You'll learn about the history of PT and how two wars and an epidemic created a need for this profession. To help you understand what makes PTs different from other health care professionals, this course will discuss the types of patients who need PT and the types of treatment PTs use. You'll understand the important difference between PTs, PT assistants, and PT aides as you come to understand the special role of PT aides.

Communication for the Physical Therapy Aide

As a PT aide, you'll communicate with many different people, so this lesson will focus on the communication skills you'll need to help you communicate with your supervising PT, patients, and their families. You'll learn about some of the challenges you'll face when communicating with sick or injured people, and how to demonstrate the traits of empathy, respect, and patience. You'll also spend some time on SOAP notes—the method many medical personnel use to document their evaluations and patient treatments.

Ethics and Law for the PT Aide

This very important lesson will help you stay out of trouble by discussing the law and ethics for the PT aide. You'll learn the differences between law and ethics and why you must be concerned about both. You'll go over the American Physical Therapy Association's Code of Ethics, relating its principles to PT aides. You'll also learn about the American Hospital Association's A Patient's Bill of Rights so you'll know how you should treat patients in different situations. You'll want to understand both negligence and malpractice, so this lesson covers those topics, too. Finally, you'll spend some time on the very important topic of patient confidentiality. You can face stiff penalties if you violate patient confidentiality, so you need to have a thorough understanding of this topic.

The Language of Physical Therapy

Have you ever noticed that every profession has its own unique language? The health care profession is no different. As a PT aide, it's vitally important that you understand the language that PTs use, which is the focus of this lesson. You'll cover planes of the body and directional terms. You'll also learn the terms that define the body's major regions and body cavities. The movements of joints have special names; this lesson will define them and include lots of graphics that demonstrate these movements. You'll finish up by learning some other terms related to function and movement in the last chapter.

Anatomy and Physiology: Part 1

In this lesson, you'll begin learning about the body's organ systems. You'll go over how your body is organized, from atoms to an entire individual. You'll learn about the muscular, skeletal, nervous, endocrine, circulatory, and lymphatic systems. You'll also learn about the organs in each of these systems, the jobs they perform, and disorders affecting these systems that are commonly treated by PTs.

Anatomy and Physiology: Part 2

In this lesson, you'll continue learning about the organ systems. To start out, you'll see how human organ systems are interrelated and how a problem with one system will affect the others. You'll then move on to a discussion of the integumentary (skin), digestive, urinary, respiratory, and reproductive systems. You'll learn about each system's organs, function, and some common disorders. You'll finish the lesson with a discussion of the most important concept in human physiology—homeostasis. Homeostasis means the drive of your body to keep many different variables, like blood pressure and temperature, within a certain range. You'll find out why this is so crucial and how you might be asked to monitor homeostasis while caring for patients.

Safety for the Physical Therapy Aide: Part 1

You'll start learning about specific safety issues in this lesson, focusing on infection control. Anyone working in healthcare must understand the meaning of infection, its causes, and how it spreads. To help you understand this, this lesson discusses the chain of infection and what you can do to break that chain so that the infection doesn't spread from one person to another. You'll spend some time on an infection called MRSA because it's so common and dangerous. Since proper hand hygiene is the most effective way to stop infection from spreading, you'll go over the Centers for Disease Control and Prevention's guidelines. You'll also learn about patient-care equipment, environmental control, and the role of vaccinations.

Safety for the Physical Therapy Aide: Part 2

You'll explore important safety issues again in this lesson, but this time, instead of infection, you'll focus on proper body mechanics and safe patient transfers. Body mechanics means the posture of your body and how you move it. You must understand proper body mechanics to protect yourself from injury. The lesson starts out with a discussion of the anatomy of the spine since the spine gets hurt most often when you ignore proper body mechanics. It talks about proper posture and the importance of paying attention to your center of gravity. It also goes over a list of principles for using proper body mechanics and guidelines for moving patients in a variety of different situations. You'll also learn about lifting machines, which PTs now commonly use to transfer patients.

Helping Patients Walk

Most people take walking for granted, but many patients must learn to walk again after an illness or injury. PTs often ask their aides to help with this, so you must understand what types of conditions make it hard for people to walk. You should also understand the normal gait cycle, so this lesson will spend some time on that topic and tell you about common deviations from normal gait. You'll also learn about different ambulatory devices, including parallel bars, walkers, crutches, and canes and how they're used in PT.

Using Physical Agents

PTs use physical agents, rather than medications or surgery, to treat patients. These agents include heat, cold, ultrasound, traction, and electricity. To explain these agents, you'll start by learning about the relationship between a disease or injury and one's ability to perform activities of daily living. You'll then follow a fictitious Mrs. Smith as she struggles to recover from a car accident. You'll learn about the physical agents her PT chooses and how they affect her body. You'll end by learning about contraindications (when an agent should never be used) and precautions (when an agent must be used with extra care).

Use of Exercise: Part 1

Along with physical agents, PTs use exercise to treat patients. In this lesson, you'll learn about three types of exercise—strength training, aerobic exercise, and range-of-motion exercise. You'll learn how muscles are put together and why resistance is necessary to build strength. This lesson will teach you about three important principles you should know when supervising a strength training program. You'll also go over aerobic exercise and learn how it increases a person's ability to use oxygen. Finally, you'll learn about range-of-motion exercises. You'll find out how PTs measure how far a patient can move a joint and why joints sometimes become limited in their motion. You'll learn about different types of range-of-motion exercises and important principles to follow.

Use of Exercise: Part 2

In the final lesson, you'll explore balance, coordination, and developmental delays. This lesson focuses on children, but the information will be helpful if you're treating adults, too. You'll learn about a special sensory system called the vestibular system and how important it is for maintaining balance. You'll view examples of activities PTs use to treat children with balance problems, and learn about the adaptive response—something PTs continually look for when treating children. The lesson will move on to a discussion of developmental coordination disorder, and you'll learn how important it is for professionals to properly diagnose this condition. Moving onto the subject of developmental delays, you'll learn about developmental milestones and how PTs treat children who fail to meet those milestones. You'll also see how PTs use developmental activities with adults who have sustained traumatic brain injuries.

What you will learn

• Learn about the human body, specific disorders, and how physical therapists can treat these disorders
• Learn about proper body mechanics and how to safely help patients with range of motion
• Explore the history of physical therapy and identify the various functions carried out by working physical therapists
• Acquire needed skills for communicating with sick or injured people, and learn how to demonstrate the traits of empathy, respect, and patience as a PT

How you will benefit

• Gain valuable communication skills and insights about the human body that are valuable in any line of work
• Attain the crucial knowledge and skills you will need to advance toward a rewarding career in physical therapy
• Discover strength training, aerobic exercises, and range-of-motion exercises that are personally beneficial to you and to those you love

Holly Trimble

Holly Trimble earned a bachelor's degree in Physical Therapy from the University of Colorado, a master's degree in Pediatric Physical Therapy from Boston University, a master's degree in Biology from the University of Nebraska at Kearney, and a doctoral degree in Physical Therapy from Arcadia University. After working as a physical therapist for many years, Dr. Trimble transitioned into teaching. She has lectured on health-related topics to all age groups and has taught middle and high school science courses in both private and public school settings. She currently teaches Anatomy and Physiology for a local community college system, where she has taught for the past 15 years. Holly received the Adjunct Faculty Excellence Award both of the years she was nominated and is the author of the eBook, "College Success Now!"

Requirements:

Hardware Requirements:

• This course can be taken on either a PC, Mac, or Chromebook.

Software Requirements:

• PC: Windows 8 or later.
• Mac: macOS 12 or later.
• Browser: The latest version of Google Chrome or Mozilla Firefox are preferred. Microsoft Edge and Safari are also compatible.
• Adobe Acrobat Reader.
• Software must be installed and fully operational before the course begins.

Other:

• Email capabilities and access to a personal email account.

Instructional Material Requirements:

The instructional materials required for this course are included in enrollment and will be available online.

Becoming a Clinical Medical Assistant

In this lesson, you'll discover the attributes, qualities, and job description of a medical assistant such as effective communication, knowledge, skill, good health and hygiene, empathy, integrity, a positive attitude, and ethical behavior. You'll explore a medical assistant's employment opportunities, which include a variety of healthcare facilities such as urgent care, outpatient clinics, laboratories, nursing facilities, and more. The lesson will also discuss a medical assistant's expected ethical behavior, scope of practice, and compliance with healthcare laws, including HIPAA (privacy and security laws).

Medical Documents, Reports, and the Medical Record

This lesson will take a closer look at the medical record and various medical documents and reports. Medical assistants are expected to document accurately and professionally in the medical record, so you will explore how the electronic signature works and why it's necessary on medical documents. The lesson will then discuss the electronic health record and the electronic medical record. You will also learn about progress notes and how they are the heart of the medical record.

Telecommunications, Enhancing the Patient Experience, and Professionalism Attributes

In this lesson, you will learn about the various types of communications in the medical office and how to deal with difficult patients. The lesson will discuss how the patient experience can influence the patient's perception of the medical assistant, the office, and the care received. You'll examine professional attributes such as being responsible, ethical, team-oriented, and to possess strong communication, interpersonal, and problem-solving skills. Today more than ever, employers are looking for employees with problem-solving skills and critical thinking capabilities.

Computers, Insurance, and Medical Billing and Coding

In this lesson, you'll learn the definitions of EMR (electronic medical record) and EHR (electronic health record) and find out why the terms aren't synonymous. You'll also learn more about the financial features of practice management software.

Major Body Systems and Pathophysiology

In this lesson, you will learn about pathophysiology and explore the 12 major body systems. You'll learn about common diseases and injuries that affect the human body.

The Chief Complaint and Patient History

This lesson will give you a comprehensive look at how to room the patient, record a proper chief complaint (CC), and collect the medical history of the patient (current, past, family, and social history) as related to your role as a clinical medical assistant. You'll learn about charting and how it can affect patients' care.

Recording Vital Signs

This lesson will discuss the importance of vital signs and measurements, and the name of the equipment used. You'll examine the procedures used to take the vital signs and body measurements of patients, which include body temperature, blood pressure, pulse (heart rate), respiratory rate, as well as body measurements such as height and weight.

The Physical Examination and the Laboratory Testing

This lesson will introduce you to the physical examination, specialty exams and procedures, and the medical laboratory. You'll explore the methods, examination positions, instruments, and supplies used by doctors to examine the body and the medical assistant's role in preparing the patient for specialty exams. This lesson will also discuss the purposes of laboratory testing, the different types of medical laboratories, and their quality standards.

Medical Asepsis, Infection Control, and Basic Microbiology

This lesson will discuss the steps in the infection cycle and about helpful and pathogenic (infectious) microorganisms. You will examine how to prevent transmission of infectious microorganisms and identify examples of personal protective equipment (PPE). The lesson will explain the importance of handwashing and the proper way to dispose of biohazard waste. Lastly, you will be introduced to the five areas of a microbiology lab.

Surgical Asepsis and Sterilization Techniques

In this lesson, you will learn about surgical asepsis and the different methods of sterilization such as autoclaving, chemical, gas, and dry heat. The lesson will discuss the importance of a surgical hand scrub in preventing healthcare-associated infections and how preparing the patient's skin with a prepping solution is a crucial step in preventing surgical site infections.

Basic Guidelines for Administration of Injections and Noninjectable Medications

This lesson will focus on the basic guidelines for the administration of injections and noninjectable medications. You will also examine how to safely administer injectable medications by discussing the parts of a needle, the gauge, how to select the proper needle, and how to determine the volume of medication. You will also learn about the types of medication containers, injection techniques, and administration of oral and inhaled medications. Lastly, this lesson will cover types of medication errors, reporting an error, and preparing an incident report.

Emergencies and First Aid in the Medical Office

In this lesson, you'll explore emergencies in the medical office and first aid. The lesson will discuss the four types of shock and description and cause of each type. You will learn how to recognize symptoms of shock and the procedures on how to treat them immediately. You will also learn about diabetic emergencies, how to recognize the symptoms of insulin shock and diabetic ketoacidosis, and about administering insulin injections. Lastly, this lesson will discuss emergencies and administering first aid for patients with open wounds, burns, and musculoskeletal injuries.

What you will learn

• Describe the job duties, skills, scope of practice, and values of a clinical medical assistant.
• Explain the information contained in different types of medical records.
• Recognize the importance of enhancing the patient experience.
• Summarize the main functions and common diseases of the 12 body systems.
• Explain the purpose of the chief complaint and identify the parts of a patient's medical history in a progress note.
• Discuss the importance of vital signs, and name the equipment used when measuring vital signs.
• Identify various methods, positions, and instruments used for examining a patient.
• Explain the importance of hand-washing and personal protective equipment in asepsis and infection control.
• List the basic guidelines for administering medications.
• Recognize emergencies in the ambulatory medical setting.

How you will benefit

• Learn if a career in healthcare is right for you and where you fit in
• Open the door to new career opportunities and discover a fulfilling career path

Meggen Leigh Green

Meggen Leigh Green is registered nurse who previously worked as clinical medical assistant for over 10 years at a large pediatric group. As a medical assistant, Meggen worked as both a clinical supervisor and team leader, overseeing all clinical staff training, ongoing education, evaluations, vaccine inventory, and laboratory certifications. She holds a Medical Assisting degree and ASN RN degree from Ivy Tech.

Requirements:

Hardware Requirements:

• This course can be taken on either a PC, Mac, or Chromebook.

Software Requirements:

• PC: Windows 8 or later.
• Mac: macOS 10.6 or later.
• Browser: The latest version of Google Chrome or Mozilla Firefox are preferred. Microsoft Edge and Safari are also compatible.
• Adobe Acrobat Reader.
• Software must be installed and fully operational before the course begins.

Other:

• Email capabilities and access to a personal email account.

Instructional Material Requirements:

The instructional materials required for this course are not included in enrollment.

• A CPT Manual, Professional Edition, and an ICD-10-CM Manual are required for this course.

Please note: Current manuals are not encouraged, but books published within the past five years work very well. It's not necessary to buy the books before the course starts. There is further guidance about books provided in the opening discussion board.

Explore a career as a medical coder and gain knowledge to help you work, with confidence, almost anywhere in the medical field from doctors' offices, clinics, hospitals, or even in the comfort of your home. This course teaches use of the CPT manual and IDC-10-CM which will give you a leg up on others who are new to this career.

Medical Coding Basics

The first lesson explores the history of medical insurance and medical coding. After that, take a few minutes to get familiar with the coding books and tools that medical coders use. This lesson finishes up with an important discussion about patient privacy and confidentiality.

Coding in the Real World

In this lesson, you'll take a close look at how medical professionals use medical codes in the real world. Get to know the common form medical coders use and explore the different types of medical codes you will find in your coding books. By the time you finish the lesson, you will understand how the different types of codes come together on a claim and how they tell the insurance company a complete story about any doctor-patient encounter.

Getting to Know Your CPT Manual

In this lesson, take a detailed tour through the CPT manual where you will find medical codes for the procedures and treatments doctors and other medical professionals provide their patients. You will learn all about the CPT symbols, modifiers, and unlisted procedures. By the end of this lesson, you will be looking up your first codes!

Getting to Know Your ICD-10-CM

Similar to the last lesson, you will take a detailed tour through the other coding book used in this course, the ICD-10-CM, which is where you will find the codes for any disease, illness, condition, or symptom that a patient may have. You will learn all about the ICD-10-CM's symbols, formatting, and other conventions; and you will learn where to find external cause codes and Z-codes. By the end of this lesson, you will begin to practice coding diagnoses.

Coding the Integumentary System

Starting with this lesson, you'll begin a series of lessons that take you in depth into one body system at a time, which will help you understand specific medical coding situations for each area of the human body. This lesson explores the integumentary (skin) system. You will review the code categories for the most common skin conditions, infections, injuries, and procedures, and then practice coding cases that involve common skin problems.

Coding the Musculoskeletal System

In this lesson, you will learn all about the musculoskeletal system and study some important musculoskeletal vocabulary. Review the code categories for the most common muscle and bone conditions and injuries and learn how to code the procedures doctors use to treat common problems.

Coding the Respiratory System

This lesson focuses on the respiratory system, and how to code the most common respiratory conditions and injuries. After that, you will practice coding the most common respiratory procedures that doctors use on their patients.

Coding the Cardiovascular System

In this lesson, you'll explore the cardiovascular system. You'll learn how to code common heart, vein, and artery conditions and diseases and how to code the procedures doctors use most often to treat these common diagnoses. As always, this lesson follows up on cardiovascular diseases and procedures with coding practice.

Coding the Digestive and Endocrine Systems

In this lesson, you will learn all about the digestive system and the endocrine system. Begin by studying some important vocabulary for both systems, and then review the code categories for the most common conditions, diseases, and injuries. After that, explore the procedures doctors perform to fix digestive and endocrine system problems.

Coding the Male and Female Genitourinary Systems

In the last of your system-specific lessons, you will review the male and female genitourinary systems; and learn how to code common conditions, diseases, and procedures for both systems. You will also spend time discussing maternity and childbirth and the special medical coding challenges you will need to consider in those cases.

Evaluation and Management (E/M) Codes

Ready to get to know Evaluation and Management codes? In this lesson, you will learn the three key components of any E/M service and discover some helpful charts you can use to narrow down an E/M code range to a final E/M code. And as you probably guessed, this lesson ends with plenty of E/M coding practice!

Surgical Packages and Modifiers

In the final lesson, you will find out what's included in a surgical package and what's not. You will also learn all about modifiers and find out why medical coders use them to let insurance companies know about special circumstances. Finally, you will put everything you've learned throughout the course together by coding some practice scenarios that incorporate all of the different types of codes!

What you will learn

• Learn how to use the CPT manual and the ICD-10-CM to find medical codes
• Discover the medical terminology, conditions, diseases, injuries, treatments, and procedures you'll see most often in each of the main systems of the human body
• Learn to come up with just the right codes to describe any medical situation

How you will benefit

• Get all the hands-on experience you'll need to code medical insurance claims with confidence
• Know how to find your way through both the CPT manual and the ICD-10-CM manual
• Begin your journey to a career as a medical coder

Jennifer Della'Zanna

Jennifer Della'Zanna has more than 20 years of experience in the healthcare industry, having worked as a medical transcriptionist, practice administrator, biller, and coding specialist. She writes courses and study guides on the use of technology in health care and regularly contributes to publications about health issues. Della'Zanna is a member of the American Academy of Professional Coders and the Association for Healthcare Documentation Integrity. She holds a Bachelor of Arts from Albright College.

Requirements:

Hardware Requirements:

• This course can be taken on either a PC, Mac, or Chromebook.

Software Requirements:

• PC: Windows 10 or later.
• Mac: macOS 10.6 or later.
• Browser: The latest version of Google Chrome or Mozilla Firefox are preferred. Microsoft Edge and Safari are also compatible.
• Adobe Acrobat Reader.
• Software must be installed and fully operational before the course begins.

Other:

• Email capabilities and access to a personal email account.

Instructional Material Requirements:

The instructional materials required for this course are included in enrollment and will be available online.

Healthcare documentation specialists used to be called medical transcriptionists, but the field has grown to include voice recognition editing and scribing duties. The expanded possibilities for employment and the upgraded skills are reflected in the new title. In this course, you will learn traditional transcription and the skills needed for voice recognition (VR) editing and scribing.

Introduction to Medical Transcription/Healthcare Documentation

In this first lesson, we'll look at the history of medical transcription as a career. You'll find out how the field has evolved from medical secretary to transcriptionist and into its modern form. You'll explore the various medical transcriptionist skills and aptitudes you'll need to succeed in the field. You'll examine the type of work HDSs produce, and we'll look at the kinds of jobs that exist today, where you might work, and what might be in store for those working in this field.

Tools of the Trade

We'll start by discussing the HDS's tools of the trade, reviewing a few of the reference books and the types of websites that HDSs use for research. Then, we'll look at the hardware and software used on the job. We'll talk you through downloading the free software we'll use in this course, and then we'll go through a quick tour of how to use it. By the end of this lesson, you'll be sitting at your computer, experiencing an actual medical dictation audio file, and using the Express Scribe software on your screen. As you work through the medical report, you'll practice starting, pausing, and rewinding the audio as you tap away on the keyboard.

Understanding Medical Records

There are nine report types that medical professionals use most often in both hospitals and clinics. In this lesson, we'll review various examples of real medical reports. We'll also do a quick review of medical correspondence. Medical letters aren't much different from traditional letters, but since you might not have typed a traditional letter in a while, a refresher might be nice. We'll finish the lesson with some specific tips about pathology reports and how to handle numbers and measurements. Then, you'll practice transcribing a medical letter and a pathology report.

Listening Carefully

We'll spend this lesson reviewing how to listen most effectively and discussing the difference between hearing and active listening. We'll also touch on many issues that keep voice recognition systems from replacing humans, including homonyms, synonyms, and antonyms. Then, we'll discuss how you can use phonetics and vowel sounds (as well as a few other tricks!) to help you figure out a word or phrase in a muddled recording. Then we'll talk a bit about the radiology department and radiology reports and finish by practicing transcribing one in today's assignment.

Grammar, Sentence Structure, and Punctuation

Lesson 5 will discuss subjects that might make you cringe a little: grammar, sentence structure, and punctuation. But this will be a painless, maybe even enjoyable, journey through some of the basic principles of writing that will help you become a better HDS. We will learn a little more about SOAP notes and then turn our attention to infectious diseases and medications. You'll also have the chance to transcribe a SOAP note and a radiology report in the lesson assignment.

Style

We'll continue our writing examination in this lesson by discussing style from the HDS perspective. Whether transcribing or editing a document produced by voice recognition, you must follow editorial directions in spelling, capitalization, and typographical display. Those directions are the style HDSs must be concerned about. You'll be surprised at how many different ways you can treat a single word. Should it be capitalized or lowercase? Should you abbreviate it, or should you spell it out? Should your numbers be in digit form or word form? These are the issues we will cover in this lesson. Finally, we'll focus on the H&P report, and you'll have the chance to practice transcribing one.

Medical Terminology and Spelling

No matter what you transcribe or edit, you can be sure that medical terminology will be a huge part of it. That's what we'll be focusing on today. Dictators aren't perfect. They might say one word when they actually mean another. Or they might say a word that has a sound-alike word, like anuresis and enuresis. If you understand medical terminology well, you can pinpoint the correct word to ensure your transcription is accurate. Then, we will review the basic nature of heart disease and its treatment. We'll also take a close look at another common disease: diabetes.

Report Formatting and Word Processing

A critical component of the HDS's work is how you put your reports together. So, we'll talk about how to break up your reports into sections with headings, subheadings, special line spacing, page breaks, and other formatting niceties. We'll also look closer at ways you can make your work easier by using word processing shortcuts, AutoText, macros, and templates. Mastering them will make you a faster and more efficient HDS! We will also focus on surgical reports. Surgical terminology is important to know, and it's also fascinating to take a look at what goes on in the operating room. The assignment for this lesson will include a surgical report to help you put to work all the new knowledge you've gained.

Checking Your Work

Another essential step in healthcare documentation is editing and proofreading your work; that's what we'll concentrate on today. We will start by sharing some editing do's and don'ts and what to look for when proofreading. We will cover a disease process that has affected virtually everyone in some way: cancer. Once you have an overview of cancer, we'll work on the consultation report. Physicians often ask specialists to evaluate their patients, especially cancer patients, further. So, this is a common report you'll likely transcribe regularly. The lesson assignment includes a consult report to transcribe, and you'll also get to practice proofreading.

Classification Systems, and Discharge and Death Summaries

So far, we've focused on the mechanical elements of medical transcription. But there is still a lot you need to know about clinical issues. So, this will be an entirely clinical lesson. We'll talk about classification systems and their transcription foibles. Plus, now that you have the bones of grammar and style down, we'll talk about some real bones. We'll begin by discussing fractures and spine levels. Finally, we'll discuss discharge and death summaries. They are very similar reports, but we'll examine some subtle differences.

Infections, Blood, and Cells

This lesson will be similar to the last in that it covers many clinical issues. It won't all be clinical, however. There are a few miscellaneous things to cover. They don't fit into neat categories, so they are all put here. Once we finish with these miscellaneous items, we'll jump back into some clinical issues, talking specifically about infections. Then, we'll focus on smaller components of the body: cells and blood. You'll notice how everything you've learned can come together in an autopsy report. This is probably the longest, most comprehensive report you'll come across. Of course, you'll also have the chance to transcribe an autopsy report in the assignment!

The Nuts and Bolts of Working as an MT

By now, you have the tools and the knowledge you need to dip your toe into the waters of healthcare documentation. But we still have a couple of big questions to answer. How do you manage your workload? Also, how do you establish yourself as a medical transcriptionist? And do you need more training? Today, we'll discuss the various ways you can work—everything from being an independent contractor all the way up to consultant work. We'll talk about additional training as well. Then, we'll take a peek at why this is an exciting time to enter the medical transcription field. We will look at some details about working in related fields, such as document integrity specialist, EHR specialist, and scribe.

What you will learn

• Explore how to work with digital tools to transcribe medical reports from audio dictation
• Apply techniques that will help you make decisions about editing reports produced by voice recognition
• Discuss major points of documentation for a variety of disease processes
• Compare skills needed for transcription, voice recognition editing, and scribe positions

How you will benefit

• Gain the knowledge needed to work in this growing field
• Possess the opportunity to practice skills that can be applied to any of the positions available to a healthcare documentation specialist
• Discover the state of the industry and where it may expand in the future
• Discuss and examine the importance of accurate medical record reporting to the health and safety of patients

Jennifer Della'Zanna

Jennifer Della'Zanna has more than 20 years of experience in the healthcare industry, having worked as a medical transcriptionist, practice administrator, biller, and coding specialist. She writes courses and study guides on the use of technology in health care and regularly contributes to publications about health issues. Della'Zanna is a member of the American Academy of Professional Coders and the Association for Healthcare Documentation Integrity. She holds a Bachelor of Arts from Albright College.

Hardware Requirements:

• This course can be taken on either a PC, Mac, or Chromebook.

Software Requirements:

• PC: Windows 8 or later.
• Mac: macOS 10.6 or later.
• Browser: The latest version of Google Chrome or Mozilla Firefox are preferred. Microsoft Edge and Safari are also compatible.
• Adobe Acrobat Reader.
• Software must be installed and fully operational before the course begins.

Other:

• Email capabilities and access to a personal email account.

Instructional Material Requirements:

The instructional materials required for this course are included in enrollment and will be available online.

Prepare for a rewarding career as an important member of the physical therapy team. This course will teach you about the workings of the human body, various disorders, patient safety, and even how to speak the language of physical therapy.

Introduction to Physical Therapy

In this lesson, you'll be introduced to the profession of physical therapy (PT). You'll learn about the history of PT and how two wars and an epidemic created a need for this profession. To help you understand what makes PTs different from other health care professionals, this course will discuss the types of patients who need PT and the types of treatment PTs use. You'll understand the important difference between PTs, PT assistants, and PT aides as you come to understand the special role of PT aides.

Communication for the Physical Therapy Aide

As a PT aide, you'll communicate with many different people, so this lesson will focus on the communication skills you'll need to help you communicate with your supervising PT, patients, and their families. You'll learn about some of the challenges you'll face when communicating with sick or injured people, and how to demonstrate the traits of empathy, respect, and patience. You'll also spend some time on SOAP notes—the method many medical personnel use to document their evaluations and patient treatments.

Ethics and Law for the PT Aide

This very important lesson will help you stay out of trouble by discussing the law and ethics for the PT aide. You'll learn the differences between law and ethics and why you must be concerned about both. You'll go over the American Physical Therapy Association's Code of Ethics, relating its principles to PT aides. You'll also learn about the American Hospital Association's A Patient's Bill of Rights so you'll know how you should treat patients in different situations. You'll want to understand both negligence and malpractice, so this lesson covers those topics, too. Finally, you'll spend some time on the very important topic of patient confidentiality. You can face stiff penalties if you violate patient confidentiality, so you need to have a thorough understanding of this topic.

The Language of Physical Therapy

Have you ever noticed that every profession has its own unique language? The health care profession is no different. As a PT aide, it's vitally important that you understand the language that PTs use, which is the focus of this lesson. You'll cover planes of the body and directional terms. You'll also learn the terms that define the body's major regions and body cavities. The movements of joints have special names; this lesson will define them and include lots of graphics that demonstrate these movements. You'll finish up by learning some other terms related to function and movement in the last chapter.

Anatomy and Physiology: Part 1

In this lesson, you'll begin learning about the body's organ systems. You'll go over how your body is organized, from atoms to an entire individual. You'll learn about the muscular, skeletal, nervous, endocrine, circulatory, and lymphatic systems. You'll also learn about the organs in each of these systems, the jobs they perform, and disorders affecting these systems that are commonly treated by PTs.

Anatomy and Physiology: Part 2

In this lesson, you'll continue learning about the organ systems. To start out, you'll see how human organ systems are interrelated and how a problem with one system will affect the others. You'll then move on to a discussion of the integumentary (skin), digestive, urinary, respiratory, and reproductive systems. You'll learn about each system's organs, function, and some common disorders. You'll finish the lesson with a discussion of the most important concept in human physiology—homeostasis. Homeostasis means the drive of your body to keep many different variables, like blood pressure and temperature, within a certain range. You'll find out why this is so crucial and how you might be asked to monitor homeostasis while caring for patients.

Safety for the Physical Therapy Aide: Part 1

You'll start learning about specific safety issues in this lesson, focusing on infection control. Anyone working in healthcare must understand the meaning of infection, its causes, and how it spreads. To help you understand this, this lesson discusses the chain of infection and what you can do to break that chain so that the infection doesn't spread from one person to another. You'll spend some time on an infection called MRSA because it's so common and dangerous. Since proper hand hygiene is the most effective way to stop infection from spreading, you'll go over the Centers for Disease Control and Prevention's guidelines. You'll also learn about patient-care equipment, environmental control, and the role of vaccinations.

Safety for the Physical Therapy Aide: Part 2

You'll explore important safety issues again in this lesson, but this time, instead of infection, you'll focus on proper body mechanics and safe patient transfers. Body mechanics means the posture of your body and how you move it. You must understand proper body mechanics to protect yourself from injury. The lesson starts out with a discussion of the anatomy of the spine since the spine gets hurt most often when you ignore proper body mechanics. It talks about proper posture and the importance of paying attention to your center of gravity. It also goes over a list of principles for using proper body mechanics and guidelines for moving patients in a variety of different situations. You'll also learn about lifting machines, which PTs now commonly use to transfer patients.

Helping Patients Walk

Most people take walking for granted, but many patients must learn to walk again after an illness or injury. PTs often ask their aides to help with this, so you must understand what types of conditions make it hard for people to walk. You should also understand the normal gait cycle, so this lesson will spend some time on that topic and tell you about common deviations from normal gait. You'll also learn about different ambulatory devices, including parallel bars, walkers, crutches, and canes and how they're used in PT.

Using Physical Agents

PTs use physical agents, rather than medications or surgery, to treat patients. These agents include heat, cold, ultrasound, traction, and electricity. To explain these agents, you'll start by learning about the relationship between a disease or injury and one's ability to perform activities of daily living. You'll then follow a fictitious Mrs. Smith as she struggles to recover from a car accident. You'll learn about the physical agents her PT chooses and how they affect her body. You'll end by learning about contraindications (when an agent should never be used) and precautions (when an agent must be used with extra care).

Use of Exercise: Part 1

Along with physical agents, PTs use exercise to treat patients. In this lesson, you'll learn about three types of exercise—strength training, aerobic exercise, and range-of-motion exercise. You'll learn how muscles are put together and why resistance is necessary to build strength. This lesson will teach you about three important principles you should know when supervising a strength training program. You'll also go over aerobic exercise and learn how it increases a person's ability to use oxygen. Finally, you'll learn about range-of-motion exercises. You'll find out how PTs measure how far a patient can move a joint and why joints sometimes become limited in their motion. You'll learn about different types of range-of-motion exercises and important principles to follow.

Use of Exercise: Part 2

In the final lesson, you'll explore balance, coordination, and developmental delays. This lesson focuses on children, but the information will be helpful if you're treating adults, too. You'll learn about a special sensory system called the vestibular system and how important it is for maintaining balance. You'll view examples of activities PTs use to treat children with balance problems, and learn about the adaptive response—something PTs continually look for when treating children. The lesson will move on to a discussion of developmental coordination disorder, and you'll learn how important it is for professionals to properly diagnose this condition. Moving onto the subject of developmental delays, you'll learn about developmental milestones and how PTs treat children who fail to meet those milestones. You'll also see how PTs use developmental activities with adults who have sustained traumatic brain injuries.

What you will learn

• Learn about the human body, specific disorders, and how physical therapists can treat these disorders
• Learn about proper body mechanics and how to safely help patients with range of motion
• Explore the history of physical therapy and identify the various functions carried out by working physical therapists
• Acquire needed skills for communicating with sick or injured people, and learn how to demonstrate the traits of empathy, respect, and patience as a PT

How you will benefit

• Gain valuable communication skills and insights about the human body that are valuable in any line of work
• Attain the crucial knowledge and skills you will need to advance toward a rewarding career in physical therapy
• Discover strength training, aerobic exercises, and range-of-motion exercises that are personally beneficial to you and to those you love

Holly Trimble

Holly Trimble earned a bachelor's degree in Physical Therapy from the University of Colorado, a master's degree in Pediatric Physical Therapy from Boston University, a master's degree in Biology from the University of Nebraska at Kearney, and a doctoral degree in Physical Therapy from Arcadia University. After working as a physical therapist for many years, Dr. Trimble transitioned into teaching. She has lectured on health-related topics to all age groups and has taught middle and high school science courses in both private and public school settings. She currently teaches Anatomy and Physiology for a local community college system, where she has taught for the past 15 years. Holly received the Adjunct Faculty Excellence Award both of the years she was nominated and is the author of the eBook, "College Success Now!"

Requirements:

Hardware Requirements:

• This course can be taken on either a PC, Mac, or Chromebook.

Software Requirements:

• PC: Windows 8 or later.
• Mac: macOS 12 or later.
• Browser: The latest version of Google Chrome or Mozilla Firefox are preferred. Microsoft Edge and Safari are also compatible.
• Adobe Acrobat Reader.
• Software must be installed and fully operational before the course begins.

Other:

• Email capabilities and access to a personal email account.

Instructional Material Requirements:

The instructional materials required for this course are included in enrollment and will be available online.

Becoming a Clinical Medical Assistant

In this lesson, you'll discover the attributes, qualities, and job description of a medical assistant such as effective communication, knowledge, skill, good health and hygiene, empathy, integrity, a positive attitude, and ethical behavior. You'll explore a medical assistant's employment opportunities, which include a variety of healthcare facilities such as urgent care, outpatient clinics, laboratories, nursing facilities, and more. The lesson will also discuss a medical assistant's expected ethical behavior, scope of practice, and compliance with healthcare laws, including HIPAA (privacy and security laws).

Medical Documents, Reports, and the Medical Record

This lesson will take a closer look at the medical record and various medical documents and reports. Medical assistants are expected to document accurately and professionally in the medical record, so you will explore how the electronic signature works and why it's necessary on medical documents. The lesson will then discuss the electronic health record and the electronic medical record. You will also learn about progress notes and how they are the heart of the medical record.

Telecommunications, Enhancing the Patient Experience, and Professionalism Attributes

In this lesson, you will learn about the various types of communications in the medical office and how to deal with difficult patients. The lesson will discuss how the patient experience can influence the patient's perception of the medical assistant, the office, and the care received. You'll examine professional attributes such as being responsible, ethical, team-oriented, and to possess strong communication, interpersonal, and problem-solving skills. Today more than ever, employers are looking for employees with problem-solving skills and critical thinking capabilities.

Computers, Insurance, and Medical Billing and Coding

In this lesson, you'll learn the definitions of EMR (electronic medical record) and EHR (electronic health record) and find out why the terms aren't synonymous. You'll also learn more about the financial features of practice management software.

Major Body Systems and Pathophysiology

In this lesson, you will learn about pathophysiology and explore the 12 major body systems. You'll learn about common diseases and injuries that affect the human body.

The Chief Complaint and Patient History

This lesson will give you a comprehensive look at how to room the patient, record a proper chief complaint (CC), and collect the medical history of the patient (current, past, family, and social history) as related to your role as a clinical medical assistant. You'll learn about charting and how it can affect patients' care.

Recording Vital Signs

This lesson will discuss the importance of vital signs and measurements, and the name of the equipment used. You'll examine the procedures used to take the vital signs and body measurements of patients, which include body temperature, blood pressure, pulse (heart rate), respiratory rate, as well as body measurements such as height and weight.

The Physical Examination and the Laboratory Testing

This lesson will introduce you to the physical examination, specialty exams and procedures, and the medical laboratory. You'll explore the methods, examination positions, instruments, and supplies used by doctors to examine the body and the medical assistant's role in preparing the patient for specialty exams. This lesson will also discuss the purposes of laboratory testing, the different types of medical laboratories, and their quality standards.

Medical Asepsis, Infection Control, and Basic Microbiology

This lesson will discuss the steps in the infection cycle and about helpful and pathogenic (infectious) microorganisms. You will examine how to prevent transmission of infectious microorganisms and identify examples of personal protective equipment (PPE). The lesson will explain the importance of handwashing and the proper way to dispose of biohazard waste. Lastly, you will be introduced to the five areas of a microbiology lab.

Surgical Asepsis and Sterilization Techniques

In this lesson, you will learn about surgical asepsis and the different methods of sterilization such as autoclaving, chemical, gas, and dry heat. The lesson will discuss the importance of a surgical hand scrub in preventing healthcare-associated infections and how preparing the patient's skin with a prepping solution is a crucial step in preventing surgical site infections.

Basic Guidelines for Administration of Injections and Noninjectable Medications

This lesson will focus on the basic guidelines for the administration of injections and noninjectable medications. You will also examine how to safely administer injectable medications by discussing the parts of a needle, the gauge, how to select the proper needle, and how to determine the volume of medication. You will also learn about the types of medication containers, injection techniques, and administration of oral and inhaled medications. Lastly, this lesson will cover types of medication errors, reporting an error, and preparing an incident report.

Emergencies and First Aid in the Medical Office

In this lesson, you'll explore emergencies in the medical office and first aid. The lesson will discuss the four types of shock and description and cause of each type. You will learn how to recognize symptoms of shock and the procedures on how to treat them immediately. You will also learn about diabetic emergencies, how to recognize the symptoms of insulin shock and diabetic ketoacidosis, and about administering insulin injections. Lastly, this lesson will discuss emergencies and administering first aid for patients with open wounds, burns, and musculoskeletal injuries.

What you will learn

• Describe the job duties, skills, scope of practice, and values of a clinical medical assistant.
• Explain the information contained in different types of medical records.
• Recognize the importance of enhancing the patient experience.
• Summarize the main functions and common diseases of the 12 body systems.
• Explain the purpose of the chief complaint and identify the parts of a patient's medical history in a progress note.
• Discuss the importance of vital signs, and name the equipment used when measuring vital signs.
• Identify various methods, positions, and instruments used for examining a patient.
• Explain the importance of hand-washing and personal protective equipment in asepsis and infection control.
• List the basic guidelines for administering medications.
• Recognize emergencies in the ambulatory medical setting.

How you will benefit

• Learn if a career in healthcare is right for you and where you fit in
• Open the door to new career opportunities and discover a fulfilling career path

Meggen Leigh Green

Meggen Leigh Green is registered nurse who previously worked as clinical medical assistant for over 10 years at a large pediatric group. As a medical assistant, Meggen worked as both a clinical supervisor and team leader, overseeing all clinical staff training, ongoing education, evaluations, vaccine inventory, and laboratory certifications. She holds a Medical Assisting degree and ASN RN degree from Ivy Tech.

Requirements:

Hardware Requirements:

• This course can be taken on either a PC, Mac, or Chromebook.

Software Requirements:

• PC: Windows 8 or later.
• Mac: macOS 10.6 or later.
• Browser: The latest version of Google Chrome or Mozilla Firefox are preferred. Microsoft Edge and Safari are also compatible.
• Adobe Acrobat Reader.
• Software must be installed and fully operational before the course begins.

Other:

• Email capabilities and access to a personal email account.

Instructional Material Requirements:

The instructional materials required for this course are not included in enrollment.

• A CPT Manual, Professional Edition, and an ICD-10-CM Manual are required for this course.

Please note: Current manuals are not encouraged, but books published within the past five years work very well. It's not necessary to buy the books before the course starts. There is further guidance about books provided in the opening discussion board.

Explore a career as a medical coder and gain knowledge to help you work, with confidence, almost anywhere in the medical field from doctors' offices, clinics, hospitals, or even in the comfort of your home. This course teaches use of the CPT manual and IDC-10-CM which will give you a leg up on others who are new to this career.

Medical Coding Basics

The first lesson explores the history of medical insurance and medical coding. After that, take a few minutes to get familiar with the coding books and tools that medical coders use. This lesson finishes up with an important discussion about patient privacy and confidentiality.

Coding in the Real World

In this lesson, you'll take a close look at how medical professionals use medical codes in the real world. Get to know the common form medical coders use and explore the different types of medical codes you will find in your coding books. By the time you finish the lesson, you will understand how the different types of codes come together on a claim and how they tell the insurance company a complete story about any doctor-patient encounter.

Getting to Know Your CPT Manual

In this lesson, take a detailed tour through the CPT manual where you will find medical codes for the procedures and treatments doctors and other medical professionals provide their patients. You will learn all about the CPT symbols, modifiers, and unlisted procedures. By the end of this lesson, you will be looking up your first codes!

Getting to Know Your ICD-10-CM

Similar to the last lesson, you will take a detailed tour through the other coding book used in this course, the ICD-10-CM, which is where you will find the codes for any disease, illness, condition, or symptom that a patient may have. You will learn all about the ICD-10-CM's symbols, formatting, and other conventions; and you will learn where to find external cause codes and Z-codes. By the end of this lesson, you will begin to practice coding diagnoses.

Coding the Integumentary System

Starting with this lesson, you'll begin a series of lessons that take you in depth into one body system at a time, which will help you understand specific medical coding situations for each area of the human body. This lesson explores the integumentary (skin) system. You will review the code categories for the most common skin conditions, infections, injuries, and procedures, and then practice coding cases that involve common skin problems.

Coding the Musculoskeletal System

In this lesson, you will learn all about the musculoskeletal system and study some important musculoskeletal vocabulary. Review the code categories for the most common muscle and bone conditions and injuries and learn how to code the procedures doctors use to treat common problems.

Coding the Respiratory System

This lesson focuses on the respiratory system, and how to code the most common respiratory conditions and injuries. After that, you will practice coding the most common respiratory procedures that doctors use on their patients.

Coding the Cardiovascular System

In this lesson, you'll explore the cardiovascular system. You'll learn how to code common heart, vein, and artery conditions and diseases and how to code the procedures doctors use most often to treat these common diagnoses. As always, this lesson follows up on cardiovascular diseases and procedures with coding practice.

Coding the Digestive and Endocrine Systems

In this lesson, you will learn all about the digestive system and the endocrine system. Begin by studying some important vocabulary for both systems, and then review the code categories for the most common conditions, diseases, and injuries. After that, explore the procedures doctors perform to fix digestive and endocrine system problems.

Coding the Male and Female Genitourinary Systems

In the last of your system-specific lessons, you will review the male and female genitourinary systems; and learn how to code common conditions, diseases, and procedures for both systems. You will also spend time discussing maternity and childbirth and the special medical coding challenges you will need to consider in those cases.

Evaluation and Management (E/M) Codes

Ready to get to know Evaluation and Management codes? In this lesson, you will learn the three key components of any E/M service and discover some helpful charts you can use to narrow down an E/M code range to a final E/M code. And as you probably guessed, this lesson ends with plenty of E/M coding practice!

Surgical Packages and Modifiers

In the final lesson, you will find out what's included in a surgical package and what's not. You will also learn all about modifiers and find out why medical coders use them to let insurance companies know about special circumstances. Finally, you will put everything you've learned throughout the course together by coding some practice scenarios that incorporate all of the different types of codes!

What you will learn

• Learn how to use the CPT manual and the ICD-10-CM to find medical codes
• Discover the medical terminology, conditions, diseases, injuries, treatments, and procedures you'll see most often in each of the main systems of the human body
• Learn to come up with just the right codes to describe any medical situation

How you will benefit

• Get all the hands-on experience you'll need to code medical insurance claims with confidence
• Know how to find your way through both the CPT manual and the ICD-10-CM manual
• Begin your journey to a career as a medical coder

Jennifer Della'Zanna

Jennifer Della'Zanna has more than 20 years of experience in the healthcare industry, having worked as a medical transcriptionist, practice administrator, biller, and coding specialist. She writes courses and study guides on the use of technology in health care and regularly contributes to publications about health issues. Della'Zanna is a member of the American Academy of Professional Coders and the Association for Healthcare Documentation Integrity. She holds a Bachelor of Arts from Albright College.

Requirements:

Hardware Requirements:

• This course can be taken on either a PC, Mac, or Chromebook.

Software Requirements:

• PC: Windows 10 or later.
• Mac: macOS 10.6 or later.
• Browser: The latest version of Google Chrome or Mozilla Firefox are preferred. Microsoft Edge and Safari are also compatible.
• Adobe Acrobat Reader.
• Software must be installed and fully operational before the course begins.

Other:

• Email capabilities and access to a personal email account.

Instructional Material Requirements:

The instructional materials required for this course are included in enrollment and will be available online.

Healthcare documentation specialists used to be called medical transcriptionists, but the field has grown to include voice recognition editing and scribing duties. The expanded possibilities for employment and the upgraded skills are reflected in the new title. In this course, you will learn traditional transcription and the skills needed for voice recognition (VR) editing and scribing.

Introduction to Medical Transcription/Healthcare Documentation

In this first lesson, we'll look at the history of medical transcription as a career. You'll find out how the field has evolved from medical secretary to transcriptionist and into its modern form. You'll explore the various medical transcriptionist skills and aptitudes you'll need to succeed in the field. You'll examine the type of work HDSs produce, and we'll look at the kinds of jobs that exist today, where you might work, and what might be in store for those working in this field.

Tools of the Trade

We'll start by discussing the HDS's tools of the trade, reviewing a few of the reference books and the types of websites that HDSs use for research. Then, we'll look at the hardware and software used on the job. We'll talk you through downloading the free software we'll use in this course, and then we'll go through a quick tour of how to use it. By the end of this lesson, you'll be sitting at your computer, experiencing an actual medical dictation audio file, and using the Express Scribe software on your screen. As you work through the medical report, you'll practice starting, pausing, and rewinding the audio as you tap away on the keyboard.

Understanding Medical Records

There are nine report types that medical professionals use most often in both hospitals and clinics. In this lesson, we'll review various examples of real medical reports. We'll also do a quick review of medical correspondence. Medical letters aren't much different from traditional letters, but since you might not have typed a traditional letter in a while, a refresher might be nice. We'll finish the lesson with some specific tips about pathology reports and how to handle numbers and measurements. Then, you'll practice transcribing a medical letter and a pathology report.

Listening Carefully

We'll spend this lesson reviewing how to listen most effectively and discussing the difference between hearing and active listening. We'll also touch on many issues that keep voice recognition systems from replacing humans, including homonyms, synonyms, and antonyms. Then, we'll discuss how you can use phonetics and vowel sounds (as well as a few other tricks!) to help you figure out a word or phrase in a muddled recording. Then we'll talk a bit about the radiology department and radiology reports and finish by practicing transcribing one in today's assignment.

Grammar, Sentence Structure, and Punctuation

Lesson 5 will discuss subjects that might make you cringe a little: grammar, sentence structure, and punctuation. But this will be a painless, maybe even enjoyable, journey through some of the basic principles of writing that will help you become a better HDS. We will learn a little more about SOAP notes and then turn our attention to infectious diseases and medications. You'll also have the chance to transcribe a SOAP note and a radiology report in the lesson assignment.

Style

We'll continue our writing examination in this lesson by discussing style from the HDS perspective. Whether transcribing or editing a document produced by voice recognition, you must follow editorial directions in spelling, capitalization, and typographical display. Those directions are the style HDSs must be concerned about. You'll be surprised at how many different ways you can treat a single word. Should it be capitalized or lowercase? Should you abbreviate it, or should you spell it out? Should your numbers be in digit form or word form? These are the issues we will cover in this lesson. Finally, we'll focus on the H&P report, and you'll have the chance to practice transcribing one.

Medical Terminology and Spelling

No matter what you transcribe or edit, you can be sure that medical terminology will be a huge part of it. That's what we'll be focusing on today. Dictators aren't perfect. They might say one word when they actually mean another. Or they might say a word that has a sound-alike word, like anuresis and enuresis. If you understand medical terminology well, you can pinpoint the correct word to ensure your transcription is accurate. Then, we will review the basic nature of heart disease and its treatment. We'll also take a close look at another common disease: diabetes.

Report Formatting and Word Processing

A critical component of the HDS's work is how you put your reports together. So, we'll talk about how to break up your reports into sections with headings, subheadings, special line spacing, page breaks, and other formatting niceties. We'll also look closer at ways you can make your work easier by using word processing shortcuts, AutoText, macros, and templates. Mastering them will make you a faster and more efficient HDS! We will also focus on surgical reports. Surgical terminology is important to know, and it's also fascinating to take a look at what goes on in the operating room. The assignment for this lesson will include a surgical report to help you put to work all the new knowledge you've gained.

Checking Your Work

Another essential step in healthcare documentation is editing and proofreading your work; that's what we'll concentrate on today. We will start by sharing some editing do's and don'ts and what to look for when proofreading. We will cover a disease process that has affected virtually everyone in some way: cancer. Once you have an overview of cancer, we'll work on the consultation report. Physicians often ask specialists to evaluate their patients, especially cancer patients, further. So, this is a common report you'll likely transcribe regularly. The lesson assignment includes a consult report to transcribe, and you'll also get to practice proofreading.

Classification Systems, and Discharge and Death Summaries

So far, we've focused on the mechanical elements of medical transcription. But there is still a lot you need to know about clinical issues. So, this will be an entirely clinical lesson. We'll talk about classification systems and their transcription foibles. Plus, now that you have the bones of grammar and style down, we'll talk about some real bones. We'll begin by discussing fractures and spine levels. Finally, we'll discuss discharge and death summaries. They are very similar reports, but we'll examine some subtle differences.

Infections, Blood, and Cells

This lesson will be similar to the last in that it covers many clinical issues. It won't all be clinical, however. There are a few miscellaneous things to cover. They don't fit into neat categories, so they are all put here. Once we finish with these miscellaneous items, we'll jump back into some clinical issues, talking specifically about infections. Then, we'll focus on smaller components of the body: cells and blood. You'll notice how everything you've learned can come together in an autopsy report. This is probably the longest, most comprehensive report you'll come across. Of course, you'll also have the chance to transcribe an autopsy report in the assignment!

The Nuts and Bolts of Working as an MT

By now, you have the tools and the knowledge you need to dip your toe into the waters of healthcare documentation. But we still have a couple of big questions to answer. How do you manage your workload? Also, how do you establish yourself as a medical transcriptionist? And do you need more training? Today, we'll discuss the various ways you can work—everything from being an independent contractor all the way up to consultant work. We'll talk about additional training as well. Then, we'll take a peek at why this is an exciting time to enter the medical transcription field. We will look at some details about working in related fields, such as document integrity specialist, EHR specialist, and scribe.

What you will learn

• Explore how to work with digital tools to transcribe medical reports from audio dictation
• Apply techniques that will help you make decisions about editing reports produced by voice recognition
• Discuss major points of documentation for a variety of disease processes
• Compare skills needed for transcription, voice recognition editing, and scribe positions

How you will benefit

• Gain the knowledge needed to work in this growing field
• Possess the opportunity to practice skills that can be applied to any of the positions available to a healthcare documentation specialist
• Discover the state of the industry and where it may expand in the future
• Discuss and examine the importance of accurate medical record reporting to the health and safety of patients

Jennifer Della'Zanna

Jennifer Della'Zanna has more than 20 years of experience in the healthcare industry, having worked as a medical transcriptionist, practice administrator, biller, and coding specialist. She writes courses and study guides on the use of technology in health care and regularly contributes to publications about health issues. Della'Zanna is a member of the American Academy of Professional Coders and the Association for Healthcare Documentation Integrity. She holds a Bachelor of Arts from Albright College.

Hardware Requirements:

• This course can be taken on either a PC, Mac, or Chromebook.

Software Requirements:

• PC: Windows 8 or later.
• Mac: macOS 10.6 or later.
• Browser: The latest version of Google Chrome or Mozilla Firefox are preferred. Microsoft Edge and Safari are also compatible.
• Adobe Acrobat Reader.
• Software must be installed and fully operational before the course begins.

Other:

• Email capabilities and access to a personal email account.

Instructional Material Requirements:

The instructional materials required for this course are included in enrollment and will be available online.

Prepare for a rewarding career as an important member of the physical therapy team. This course will teach you about the workings of the human body, various disorders, patient safety, and even how to speak the language of physical therapy.

Introduction to Physical Therapy

In this lesson, you'll be introduced to the profession of physical therapy (PT). You'll learn about the history of PT and how two wars and an epidemic created a need for this profession. To help you understand what makes PTs different from other health care professionals, this course will discuss the types of patients who need PT and the types of treatment PTs use. You'll understand the important difference between PTs, PT assistants, and PT aides as you come to understand the special role of PT aides.

Communication for the Physical Therapy Aide

As a PT aide, you'll communicate with many different people, so this lesson will focus on the communication skills you'll need to help you communicate with your supervising PT, patients, and their families. You'll learn about some of the challenges you'll face when communicating with sick or injured people, and how to demonstrate the traits of empathy, respect, and patience. You'll also spend some time on SOAP notes—the method many medical personnel use to document their evaluations and patient treatments.

Ethics and Law for the PT Aide

This very important lesson will help you stay out of trouble by discussing the law and ethics for the PT aide. You'll learn the differences between law and ethics and why you must be concerned about both. You'll go over the American Physical Therapy Association's Code of Ethics, relating its principles to PT aides. You'll also learn about the American Hospital Association's A Patient's Bill of Rights so you'll know how you should treat patients in different situations. You'll want to understand both negligence and malpractice, so this lesson covers those topics, too. Finally, you'll spend some time on the very important topic of patient confidentiality. You can face stiff penalties if you violate patient confidentiality, so you need to have a thorough understanding of this topic.

The Language of Physical Therapy

Have you ever noticed that every profession has its own unique language? The health care profession is no different. As a PT aide, it's vitally important that you understand the language that PTs use, which is the focus of this lesson. You'll cover planes of the body and directional terms. You'll also learn the terms that define the body's major regions and body cavities. The movements of joints have special names; this lesson will define them and include lots of graphics that demonstrate these movements. You'll finish up by learning some other terms related to function and movement in the last chapter.

Anatomy and Physiology: Part 1

In this lesson, you'll begin learning about the body's organ systems. You'll go over how your body is organized, from atoms to an entire individual. You'll learn about the muscular, skeletal, nervous, endocrine, circulatory, and lymphatic systems. You'll also learn about the organs in each of these systems, the jobs they perform, and disorders affecting these systems that are commonly treated by PTs.

Anatomy and Physiology: Part 2

In this lesson, you'll continue learning about the organ systems. To start out, you'll see how human organ systems are interrelated and how a problem with one system will affect the others. You'll then move on to a discussion of the integumentary (skin), digestive, urinary, respiratory, and reproductive systems. You'll learn about each system's organs, function, and some common disorders. You'll finish the lesson with a discussion of the most important concept in human physiology—homeostasis. Homeostasis means the drive of your body to keep many different variables, like blood pressure and temperature, within a certain range. You'll find out why this is so crucial and how you might be asked to monitor homeostasis while caring for patients.

Safety for the Physical Therapy Aide: Part 1

You'll start learning about specific safety issues in this lesson, focusing on infection control. Anyone working in healthcare must understand the meaning of infection, its causes, and how it spreads. To help you understand this, this lesson discusses the chain of infection and what you can do to break that chain so that the infection doesn't spread from one person to another. You'll spend some time on an infection called MRSA because it's so common and dangerous. Since proper hand hygiene is the most effective way to stop infection from spreading, you'll go over the Centers for Disease Control and Prevention's guidelines. You'll also learn about patient-care equipment, environmental control, and the role of vaccinations.

Safety for the Physical Therapy Aide: Part 2

You'll explore important safety issues again in this lesson, but this time, instead of infection, you'll focus on proper body mechanics and safe patient transfers. Body mechanics means the posture of your body and how you move it. You must understand proper body mechanics to protect yourself from injury. The lesson starts out with a discussion of the anatomy of the spine since the spine gets hurt most often when you ignore proper body mechanics. It talks about proper posture and the importance of paying attention to your center of gravity. It also goes over a list of principles for using proper body mechanics and guidelines for moving patients in a variety of different situations. You'll also learn about lifting machines, which PTs now commonly use to transfer patients.

Helping Patients Walk

Most people take walking for granted, but many patients must learn to walk again after an illness or injury. PTs often ask their aides to help with this, so you must understand what types of conditions make it hard for people to walk. You should also understand the normal gait cycle, so this lesson will spend some time on that topic and tell you about common deviations from normal gait. You'll also learn about different ambulatory devices, including parallel bars, walkers, crutches, and canes and how they're used in PT.

Using Physical Agents

PTs use physical agents, rather than medications or surgery, to treat patients. These agents include heat, cold, ultrasound, traction, and electricity. To explain these agents, you'll start by learning about the relationship between a disease or injury and one's ability to perform activities of daily living. You'll then follow a fictitious Mrs. Smith as she struggles to recover from a car accident. You'll learn about the physical agents her PT chooses and how they affect her body. You'll end by learning about contraindications (when an agent should never be used) and precautions (when an agent must be used with extra care).

Use of Exercise: Part 1

Along with physical agents, PTs use exercise to treat patients. In this lesson, you'll learn about three types of exercise—strength training, aerobic exercise, and range-of-motion exercise. You'll learn how muscles are put together and why resistance is necessary to build strength. This lesson will teach you about three important principles you should know when supervising a strength training program. You'll also go over aerobic exercise and learn how it increases a person's ability to use oxygen. Finally, you'll learn about range-of-motion exercises. You'll find out how PTs measure how far a patient can move a joint and why joints sometimes become limited in their motion. You'll learn about different types of range-of-motion exercises and important principles to follow.

Use of Exercise: Part 2

In the final lesson, you'll explore balance, coordination, and developmental delays. This lesson focuses on children, but the information will be helpful if you're treating adults, too. You'll learn about a special sensory system called the vestibular system and how important it is for maintaining balance. You'll view examples of activities PTs use to treat children with balance problems, and learn about the adaptive response—something PTs continually look for when treating children. The lesson will move on to a discussion of developmental coordination disorder, and you'll learn how important it is for professionals to properly diagnose this condition. Moving onto the subject of developmental delays, you'll learn about developmental milestones and how PTs treat children who fail to meet those milestones. You'll also see how PTs use developmental activities with adults who have sustained traumatic brain injuries.

What you will learn

• Learn about the human body, specific disorders, and how physical therapists can treat these disorders
• Learn about proper body mechanics and how to safely help patients with range of motion
• Explore the history of physical therapy and identify the various functions carried out by working physical therapists
• Acquire needed skills for communicating with sick or injured people, and learn how to demonstrate the traits of empathy, respect, and patience as a PT

How you will benefit

• Gain valuable communication skills and insights about the human body that are valuable in any line of work
• Attain the crucial knowledge and skills you will need to advance toward a rewarding career in physical therapy
• Discover strength training, aerobic exercises, and range-of-motion exercises that are personally beneficial to you and to those you love

Holly Trimble

Holly Trimble earned a bachelor's degree in Physical Therapy from the University of Colorado, a master's degree in Pediatric Physical Therapy from Boston University, a master's degree in Biology from the University of Nebraska at Kearney, and a doctoral degree in Physical Therapy from Arcadia University. After working as a physical therapist for many years, Dr. Trimble transitioned into teaching. She has lectured on health-related topics to all age groups and has taught middle and high school science courses in both private and public school settings. She currently teaches Anatomy and Physiology for a local community college system, where she has taught for the past 15 years. Holly received the Adjunct Faculty Excellence Award both of the years she was nominated and is the author of the eBook, "College Success Now!"

Requirements:

Hardware Requirements:

• This course can be taken on either a PC, Mac, or Chromebook.

Software Requirements:

• PC: Windows 8 or later.
• Mac: macOS 12 or later.
• Browser: The latest version of Google Chrome or Mozilla Firefox are preferred. Microsoft Edge and Safari are also compatible.
• Adobe Acrobat Reader.
• Software must be installed and fully operational before the course begins.

Other:

• Email capabilities and access to a personal email account.

Instructional Material Requirements:

The instructional materials required for this course are included in enrollment and will be available online.

Becoming a Clinical Medical Assistant

In this lesson, you'll discover the attributes, qualities, and job description of a medical assistant such as effective communication, knowledge, skill, good health and hygiene, empathy, integrity, a positive attitude, and ethical behavior. You'll explore a medical assistant's employment opportunities, which include a variety of healthcare facilities such as urgent care, outpatient clinics, laboratories, nursing facilities, and more. The lesson will also discuss a medical assistant's expected ethical behavior, scope of practice, and compliance with healthcare laws, including HIPAA (privacy and security laws).

Medical Documents, Reports, and the Medical Record

This lesson will take a closer look at the medical record and various medical documents and reports. Medical assistants are expected to document accurately and professionally in the medical record, so you will explore how the electronic signature works and why it's necessary on medical documents. The lesson will then discuss the electronic health record and the electronic medical record. You will also learn about progress notes and how they are the heart of the medical record.

Telecommunications, Enhancing the Patient Experience, and Professionalism Attributes

In this lesson, you will learn about the various types of communications in the medical office and how to deal with difficult patients. The lesson will discuss how the patient experience can influence the patient's perception of the medical assistant, the office, and the care received. You'll examine professional attributes such as being responsible, ethical, team-oriented, and to possess strong communication, interpersonal, and problem-solving skills. Today more than ever, employers are looking for employees with problem-solving skills and critical thinking capabilities.

Computers, Insurance, and Medical Billing and Coding

In this lesson, you'll learn the definitions of EMR (electronic medical record) and EHR (electronic health record) and find out why the terms aren't synonymous. You'll also learn more about the financial features of practice management software.

Major Body Systems and Pathophysiology

In this lesson, you will learn about pathophysiology and explore the 12 major body systems. You'll learn about common diseases and injuries that affect the human body.

The Chief Complaint and Patient History

This lesson will give you a comprehensive look at how to room the patient, record a proper chief complaint (CC), and collect the medical history of the patient (current, past, family, and social history) as related to your role as a clinical medical assistant. You'll learn about charting and how it can affect patients' care.

Recording Vital Signs

This lesson will discuss the importance of vital signs and measurements, and the name of the equipment used. You'll examine the procedures used to take the vital signs and body measurements of patients, which include body temperature, blood pressure, pulse (heart rate), respiratory rate, as well as body measurements such as height and weight.

The Physical Examination and the Laboratory Testing

This lesson will introduce you to the physical examination, specialty exams and procedures, and the medical laboratory. You'll explore the methods, examination positions, instruments, and supplies used by doctors to examine the body and the medical assistant's role in preparing the patient for specialty exams. This lesson will also discuss the purposes of laboratory testing, the different types of medical laboratories, and their quality standards.

Medical Asepsis, Infection Control, and Basic Microbiology

This lesson will discuss the steps in the infection cycle and about helpful and pathogenic (infectious) microorganisms. You will examine how to prevent transmission of infectious microorganisms and identify examples of personal protective equipment (PPE). The lesson will explain the importance of handwashing and the proper way to dispose of biohazard waste. Lastly, you will be introduced to the five areas of a microbiology lab.

Surgical Asepsis and Sterilization Techniques

In this lesson, you will learn about surgical asepsis and the different methods of sterilization such as autoclaving, chemical, gas, and dry heat. The lesson will discuss the importance of a surgical hand scrub in preventing healthcare-associated infections and how preparing the patient's skin with a prepping solution is a crucial step in preventing surgical site infections.

Basic Guidelines for Administration of Injections and Noninjectable Medications

This lesson will focus on the basic guidelines for the administration of injections and noninjectable medications. You will also examine how to safely administer injectable medications by discussing the parts of a needle, the gauge, how to select the proper needle, and how to determine the volume of medication. You will also learn about the types of medication containers, injection techniques, and administration of oral and inhaled medications. Lastly, this lesson will cover types of medication errors, reporting an error, and preparing an incident report.

Emergencies and First Aid in the Medical Office

In this lesson, you'll explore emergencies in the medical office and first aid. The lesson will discuss the four types of shock and description and cause of each type. You will learn how to recognize symptoms of shock and the procedures on how to treat them immediately. You will also learn about diabetic emergencies, how to recognize the symptoms of insulin shock and diabetic ketoacidosis, and about administering insulin injections. Lastly, this lesson will discuss emergencies and administering first aid for patients with open wounds, burns, and musculoskeletal injuries.

What you will learn

• Describe the job duties, skills, scope of practice, and values of a clinical medical assistant.
• Explain the information contained in different types of medical records.
• Recognize the importance of enhancing the patient experience.
• Summarize the main functions and common diseases of the 12 body systems.
• Explain the purpose of the chief complaint and identify the parts of a patient's medical history in a progress note.
• Discuss the importance of vital signs, and name the equipment used when measuring vital signs.
• Identify various methods, positions, and instruments used for examining a patient.
• Explain the importance of hand-washing and personal protective equipment in asepsis and infection control.
• List the basic guidelines for administering medications.
• Recognize emergencies in the ambulatory medical setting.

How you will benefit

• Learn if a career in healthcare is right for you and where you fit in
• Open the door to new career opportunities and discover a fulfilling career path

Meggen Leigh Green

Meggen Leigh Green is registered nurse who previously worked as clinical medical assistant for over 10 years at a large pediatric group. As a medical assistant, Meggen worked as both a clinical supervisor and team leader, overseeing all clinical staff training, ongoing education, evaluations, vaccine inventory, and laboratory certifications. She holds a Medical Assisting degree and ASN RN degree from Ivy Tech.

Requirements:

Hardware Requirements:

• This course can be taken on either a PC, Mac, or Chromebook.

Software Requirements:

• PC: Windows 8 or later.
• Mac: macOS 10.6 or later.
• Browser: The latest version of Google Chrome or Mozilla Firefox are preferred. Microsoft Edge and Safari are also compatible.
• Adobe Acrobat Reader.
• Software must be installed and fully operational before the course begins.

Other:

• Email capabilities and access to a personal email account.

Instructional Material Requirements:

The instructional materials required for this course are not included in enrollment.

• A CPT Manual, Professional Edition, and an ICD-10-CM Manual are required for this course.

Please note: Current manuals are not encouraged, but books published within the past five years work very well. It's not necessary to buy the books before the course starts. There is further guidance about books provided in the opening discussion board.

Explore a career as a medical coder and gain knowledge to help you work, with confidence, almost anywhere in the medical field from doctors' offices, clinics, hospitals, or even in the comfort of your home. This course teaches use of the CPT manual and IDC-10-CM which will give you a leg up on others who are new to this career.

Medical Coding Basics

The first lesson explores the history of medical insurance and medical coding. After that, take a few minutes to get familiar with the coding books and tools that medical coders use. This lesson finishes up with an important discussion about patient privacy and confidentiality.

Coding in the Real World

In this lesson, you'll take a close look at how medical professionals use medical codes in the real world. Get to know the common form medical coders use and explore the different types of medical codes you will find in your coding books. By the time you finish the lesson, you will understand how the different types of codes come together on a claim and how they tell the insurance company a complete story about any doctor-patient encounter.

Getting to Know Your CPT Manual

In this lesson, take a detailed tour through the CPT manual where you will find medical codes for the procedures and treatments doctors and other medical professionals provide their patients. You will learn all about the CPT symbols, modifiers, and unlisted procedures. By the end of this lesson, you will be looking up your first codes!

Getting to Know Your ICD-10-CM

Similar to the last lesson, you will take a detailed tour through the other coding book used in this course, the ICD-10-CM, which is where you will find the codes for any disease, illness, condition, or symptom that a patient may have. You will learn all about the ICD-10-CM's symbols, formatting, and other conventions; and you will learn where to find external cause codes and Z-codes. By the end of this lesson, you will begin to practice coding diagnoses.

Coding the Integumentary System

Starting with this lesson, you'll begin a series of lessons that take you in depth into one body system at a time, which will help you understand specific medical coding situations for each area of the human body. This lesson explores the integumentary (skin) system. You will review the code categories for the most common skin conditions, infections, injuries, and procedures, and then practice coding cases that involve common skin problems.

Coding the Musculoskeletal System

In this lesson, you will learn all about the musculoskeletal system and study some important musculoskeletal vocabulary. Review the code categories for the most common muscle and bone conditions and injuries and learn how to code the procedures doctors use to treat common problems.

Coding the Respiratory System

This lesson focuses on the respiratory system, and how to code the most common respiratory conditions and injuries. After that, you will practice coding the most common respiratory procedures that doctors use on their patients.

Coding the Cardiovascular System

In this lesson, you'll explore the cardiovascular system. You'll learn how to code common heart, vein, and artery conditions and diseases and how to code the procedures doctors use most often to treat these common diagnoses. As always, this lesson follows up on cardiovascular diseases and procedures with coding practice.

Coding the Digestive and Endocrine Systems

In this lesson, you will learn all about the digestive system and the endocrine system. Begin by studying some important vocabulary for both systems, and then review the code categories for the most common conditions, diseases, and injuries. After that, explore the procedures doctors perform to fix digestive and endocrine system problems.

Coding the Male and Female Genitourinary Systems

In the last of your system-specific lessons, you will review the male and female genitourinary systems; and learn how to code common conditions, diseases, and procedures for both systems. You will also spend time discussing maternity and childbirth and the special medical coding challenges you will need to consider in those cases.

Evaluation and Management (E/M) Codes

Ready to get to know Evaluation and Management codes? In this lesson, you will learn the three key components of any E/M service and discover some helpful charts you can use to narrow down an E/M code range to a final E/M code. And as you probably guessed, this lesson ends with plenty of E/M coding practice!

Surgical Packages and Modifiers

In the final lesson, you will find out what's included in a surgical package and what's not. You will also learn all about modifiers and find out why medical coders use them to let insurance companies know about special circumstances. Finally, you will put everything you've learned throughout the course together by coding some practice scenarios that incorporate all of the different types of codes!

What you will learn

• Learn how to use the CPT manual and the ICD-10-CM to find medical codes
• Discover the medical terminology, conditions, diseases, injuries, treatments, and procedures you'll see most often in each of the main systems of the human body
• Learn to come up with just the right codes to describe any medical situation

How you will benefit

• Get all the hands-on experience you'll need to code medical insurance claims with confidence
• Know how to find your way through both the CPT manual and the ICD-10-CM manual
• Begin your journey to a career as a medical coder

Jennifer Della'Zanna

Jennifer Della'Zanna has more than 20 years of experience in the healthcare industry, having worked as a medical transcriptionist, practice administrator, biller, and coding specialist. She writes courses and study guides on the use of technology in health care and regularly contributes to publications about health issues. Della'Zanna is a member of the American Academy of Professional Coders and the Association for Healthcare Documentation Integrity. She holds a Bachelor of Arts from Albright College.

Requirements:

Hardware Requirements:

• This course can be taken on either a PC, Mac, or Chromebook.

Software Requirements:

• PC: Windows 10 or later.
• Mac: macOS 10.6 or later.
• Browser: The latest version of Google Chrome or Mozilla Firefox are preferred. Microsoft Edge and Safari are also compatible.
• Adobe Acrobat Reader.
• Software must be installed and fully operational before the course begins.

Other:

• Email capabilities and access to a personal email account.

Instructional Material Requirements:

The instructional materials required for this course are included in enrollment and will be available online.

Healthcare documentation specialists used to be called medical transcriptionists, but the field has grown to include voice recognition editing and scribing duties. The expanded possibilities for employment and the upgraded skills are reflected in the new title. In this course, you will learn traditional transcription and the skills needed for voice recognition (VR) editing and scribing.

Introduction to Medical Transcription/Healthcare Documentation

In this first lesson, we'll look at the history of medical transcription as a career. You'll find out how the field has evolved from medical secretary to transcriptionist and into its modern form. You'll explore the various medical transcriptionist skills and aptitudes you'll need to succeed in the field. You'll examine the type of work HDSs produce, and we'll look at the kinds of jobs that exist today, where you might work, and what might be in store for those working in this field.

Tools of the Trade

We'll start by discussing the HDS's tools of the trade, reviewing a few of the reference books and the types of websites that HDSs use for research. Then, we'll look at the hardware and software used on the job. We'll talk you through downloading the free software we'll use in this course, and then we'll go through a quick tour of how to use it. By the end of this lesson, you'll be sitting at your computer, experiencing an actual medical dictation audio file, and using the Express Scribe software on your screen. As you work through the medical report, you'll practice starting, pausing, and rewinding the audio as you tap away on the keyboard.

Understanding Medical Records

There are nine report types that medical professionals use most often in both hospitals and clinics. In this lesson, we'll review various examples of real medical reports. We'll also do a quick review of medical correspondence. Medical letters aren't much different from traditional letters, but since you might not have typed a traditional letter in a while, a refresher might be nice. We'll finish the lesson with some specific tips about pathology reports and how to handle numbers and measurements. Then, you'll practice transcribing a medical letter and a pathology report.

Listening Carefully

We'll spend this lesson reviewing how to listen most effectively and discussing the difference between hearing and active listening. We'll also touch on many issues that keep voice recognition systems from replacing humans, including homonyms, synonyms, and antonyms. Then, we'll discuss how you can use phonetics and vowel sounds (as well as a few other tricks!) to help you figure out a word or phrase in a muddled recording. Then we'll talk a bit about the radiology department and radiology reports and finish by practicing transcribing one in today's assignment.

Grammar, Sentence Structure, and Punctuation

Lesson 5 will discuss subjects that might make you cringe a little: grammar, sentence structure, and punctuation. But this will be a painless, maybe even enjoyable, journey through some of the basic principles of writing that will help you become a better HDS. We will learn a little more about SOAP notes and then turn our attention to infectious diseases and medications. You'll also have the chance to transcribe a SOAP note and a radiology report in the lesson assignment.

Style

We'll continue our writing examination in this lesson by discussing style from the HDS perspective. Whether transcribing or editing a document produced by voice recognition, you must follow editorial directions in spelling, capitalization, and typographical display. Those directions are the style HDSs must be concerned about. You'll be surprised at how many different ways you can treat a single word. Should it be capitalized or lowercase? Should you abbreviate it, or should you spell it out? Should your numbers be in digit form or word form? These are the issues we will cover in this lesson. Finally, we'll focus on the H&P report, and you'll have the chance to practice transcribing one.

Medical Terminology and Spelling

No matter what you transcribe or edit, you can be sure that medical terminology will be a huge part of it. That's what we'll be focusing on today. Dictators aren't perfect. They might say one word when they actually mean another. Or they might say a word that has a sound-alike word, like anuresis and enuresis. If you understand medical terminology well, you can pinpoint the correct word to ensure your transcription is accurate. Then, we will review the basic nature of heart disease and its treatment. We'll also take a close look at another common disease: diabetes.

Report Formatting and Word Processing

A critical component of the HDS's work is how you put your reports together. So, we'll talk about how to break up your reports into sections with headings, subheadings, special line spacing, page breaks, and other formatting niceties. We'll also look closer at ways you can make your work easier by using word processing shortcuts, AutoText, macros, and templates. Mastering them will make you a faster and more efficient HDS! We will also focus on surgical reports. Surgical terminology is important to know, and it's also fascinating to take a look at what goes on in the operating room. The assignment for this lesson will include a surgical report to help you put to work all the new knowledge you've gained.

Checking Your Work

Another essential step in healthcare documentation is editing and proofreading your work; that's what we'll concentrate on today. We will start by sharing some editing do's and don'ts and what to look for when proofreading. We will cover a disease process that has affected virtually everyone in some way: cancer. Once you have an overview of cancer, we'll work on the consultation report. Physicians often ask specialists to evaluate their patients, especially cancer patients, further. So, this is a common report you'll likely transcribe regularly. The lesson assignment includes a consult report to transcribe, and you'll also get to practice proofreading.

Classification Systems, and Discharge and Death Summaries

So far, we've focused on the mechanical elements of medical transcription. But there is still a lot you need to know about clinical issues. So, this will be an entirely clinical lesson. We'll talk about classification systems and their transcription foibles. Plus, now that you have the bones of grammar and style down, we'll talk about some real bones. We'll begin by discussing fractures and spine levels. Finally, we'll discuss discharge and death summaries. They are very similar reports, but we'll examine some subtle differences.

Infections, Blood, and Cells

This lesson will be similar to the last in that it covers many clinical issues. It won't all be clinical, however. There are a few miscellaneous things to cover. They don't fit into neat categories, so they are all put here. Once we finish with these miscellaneous items, we'll jump back into some clinical issues, talking specifically about infections. Then, we'll focus on smaller components of the body: cells and blood. You'll notice how everything you've learned can come together in an autopsy report. This is probably the longest, most comprehensive report you'll come across. Of course, you'll also have the chance to transcribe an autopsy report in the assignment!

The Nuts and Bolts of Working as an MT

By now, you have the tools and the knowledge you need to dip your toe into the waters of healthcare documentation. But we still have a couple of big questions to answer. How do you manage your workload? Also, how do you establish yourself as a medical transcriptionist? And do you need more training? Today, we'll discuss the various ways you can work—everything from being an independent contractor all the way up to consultant work. We'll talk about additional training as well. Then, we'll take a peek at why this is an exciting time to enter the medical transcription field. We will look at some details about working in related fields, such as document integrity specialist, EHR specialist, and scribe.

What you will learn

• Explore how to work with digital tools to transcribe medical reports from audio dictation
• Apply techniques that will help you make decisions about editing reports produced by voice recognition
• Discuss major points of documentation for a variety of disease processes
• Compare skills needed for transcription, voice recognition editing, and scribe positions

How you will benefit

• Gain the knowledge needed to work in this growing field
• Possess the opportunity to practice skills that can be applied to any of the positions available to a healthcare documentation specialist
• Discover the state of the industry and where it may expand in the future
• Discuss and examine the importance of accurate medical record reporting to the health and safety of patients

Jennifer Della'Zanna

Jennifer Della'Zanna has more than 20 years of experience in the healthcare industry, having worked as a medical transcriptionist, practice administrator, biller, and coding specialist. She writes courses and study guides on the use of technology in health care and regularly contributes to publications about health issues. Della'Zanna is a member of the American Academy of Professional Coders and the Association for Healthcare Documentation Integrity. She holds a Bachelor of Arts from Albright College.