OFFT 2041 - Healthcare Documentation Fundamentals

1. Body system terminology
2. Document formatting
3. English spelling and grammar
4. Equipment operation
5. Professional transcription organizations code of ethics
6. Reference material use
7. Organization’s code of ethics

1. Transcribe commonly dictated reports from a variety of medical specialties.
2. Incorporate medical terminology into medical documents using a body system approach.
3. Demonstrate use of language skills and medical knowledge to edit, revise, and clarify while transcribing dictation, without altering the meaning of the dictation or changing the author’s style.
4. Operate transcription equipment.
5. Recognize situations requiring assistance from supervisor, coworker, or originator in order to understand dictation and transcribe reports.
6. Demonstrate use of medical references.
7. Describe professional code of ethics.
8. edit speech-recognized medical reports.
9. identify situations requiring assistance from supervisor, coworker, or originator in order to understand dictation and transcribe reports.

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