For your final project, you will assume the role of a medical scribe in a healthcare organization. You will complete a series of tasks that a medical scribe would
complete in the field on a daily basis and document these tasks in the Final Project Portfolio Template. You will submit your completed template to your
instructor. To begin, you will assist a physician in documenting notes from a patient record by building medical terms, and ensuring the terms are spelled correctly.
You will also provide a recording of the pronunciation of the terms. Second, you will review medical documentation in a patient record to ensure accuracy. You
will identify inaccuracies of spelling and interpretation, and provide the accurate spelling and revised SOAP note. For your third task, you will gather information
to be used by the physician to educate a patient on their diagnosis. You will interpret the medical record to identify key terms, and then break down, define, and
pronounce these terms. Note that these terms will all be constructed terms. To complete your task, you will provide a final summary of the diagnosis.
For support on using Vocaroo, refer to the Vocaroo Tutorial.
Specifically, the following critical elements must be addressed:
I. Documenting Patient Information: To begin your day, a physician has asked you to assist in documenting his notes from Patient Record One. The
physician has bolded the words or phrases that need interpreting in the Progress Notes. Based on these notes, build the medical terms that are
described, and add these to the Final Project Portfolio Template, making sure that each term is spelled correctly. Then, using a recording tool, such as
Vocaroo, record the medical terms. Add your recording to the Final Project Portfolio Template.
A. Build medical terms by using the appropriate word parts.
B. Be sure that the medical terms are spelled accurately.
C. Provide the effective pronunciation of the medical terms.
II. Reviewing Records for Accuracy: In the second part of your day, you will review medical documentation to ensure all information is accurate. Your task
is to review the SOAP note in Patient Record Two to ensure all medical terms are spelled correctly, and that the interpretation of the notes are accurate,
based on the patient’s diagnosis and result of relevant vitals. Document your review of the record in the Final Project Portfolio Template.
A. Identify the medical terms that are spelled incorrectly in the note.
B. Provide the accurate spelling for the medical terms.
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C. Identify inaccuracies of interpretation in the SOAP note, and explain why the elements you identified are inaccurate.
D. Explain how to revise the SOAP note to include the correct medical terms and an accurate documentation of the patient’s diagnosis.
III. Interpreting Patient Information: To end your day, a physician has asked you to gather information she can use to educate a patient on how to interpret
their medical record and diagnosis. She has asked you to focus specifically on the History & Physical exam section of Patient Record Three, and the list of
medical terms she has compiled from the record. This list is located in the Final Project Portfolio Template. Note that each term the physician has listed
is a constructed term. Be sure to include a recording of the pronunciation of the medical terms in your Final Project Portfolio Template, using a tool such
as Vocaroo.
A. Break the medical terms into their word parts, and define each word part.
B. Define each medical term. Note: you previously defined the word parts, but now you will define each medical term as a whole.
C. Provide the effective pronunciation of the medical terms.
D. Explain the guidelines for building medical terms, providing specific examples using the terms from the patient record.
E. Provide a summary for the patient that clearly and succinctly describes the patient’s diagnosis detailed in the medical record.

Answer rating: 100% (QA)

The physician has asked the medical scribe to assist in documenting his notes from Patient Record One The physician has bolded the words or phrases that need interpreting in the Progress Notes Based o... View the full answer