SURG 248A: Advanced Medical Scribe Training
3 Units | Medical Option (Med-Ltr-CR/NC)
Course Instructor:
Dr. Jessica Pierog, DO, MS
Division of Emergency Medicine
jpierog@stanford.edu
Teaching Assistant:
Lauren Wedekind
Human Biology, Education
LWedekind@stanford.edu
Recommended Textbook
The Ultimate Medical Scribe Handbook: Emergency Department 4th Edition. By
Aaron Thompson and Kyle Kingsley MD. CreateSpace Independent Publishing
Platform; 4th edition (April 16, 2014). ISBN: 9781496190857.
Course Description:
Advanced Medical Scribe Training will provide in-depth medical scribe training and
continuing education through case presentation and review, and medical simulations.
Additionally, students will be given opportunities to shadow physicians and patient flow
coordinators (paid medical scribes hired by Stanford Health Care) in the Stanford
Hospital Emergency Department with instructor consent.
A medical scribe works to help create a patient care record under the direct supervision of
a physician. The scribe documents the patient chief complaint, history of current illness,
past medical, social and family history, review of physical systems, clinical course,
procedures, lab results and other pertinent patient information for a patient visit.
Additionally, the role of the medical scribe can be a bridge to other health care
professions such as a physician, nurse, physician assistant, EMT/Paramedic, or health
care administrator.
Prerequisites:
 Proficiency in Microsoft Word and Microsoft Excel
 Skills: listening, multi-tasking, attention to detail, and typing proficiency
 To be able to work in a medical setting, students must have available
documentation for: high school graduation or GED, immunizations and annual flu
vaccination, completion tuberculosis screening test, pre-employment drug screen,
and a criminal background check.
Learning Objectives:
1. Develop a knowledge of patient care clinical documentation
2. Gain a knowledge of the associated medical, legal, ethical and regulatory
requirements of medical care documentation
3. Gain valuable experience in medical care documentation:
 Accompany physician into patient exam room
 Transcribe findings at the bedside
 Document patient’s chief complaint and related history
 Document medical / surgical consultation
 Document review of systems and physical examination
 Record patient care activities
 Transcribe and input as supervised by the physicians orders, laboratory
tests, radiology tests, medications
 Document clinical progress
 Document procedures and interventions
 Capture diagnosis, discharge, follow up instructions
 Compliance with regulatory measures
Overall, this course aims to prepare students to work as employed medical scribes
(patient flow coordinators) in any hospital emergency department, and with further
specialized training afterward, in any scribe-employing clinic.
Student Assessment/Grading:

Components:
1. Weekly attendance and participation (25%): Students are
responsible for regularly attending class and completing the outside
assigned readings before the start of class and contributing to in class
discussions.
2. Homework (25%): Students are responsible for on time homework on
the previous class.
3. Patient scenario documentation (25%): Students are responsible for
completing and submitting 10 patient care electronic medical records
meeting all standards of medical record documentation.
4. Final Exam (25%)

No extra credit will be allowed

The percentile grades will be curved

Allocations of grades will be as follows:
o Grade of “A” is defined as  90%
o Grade of “B” is defined as  80% but < 90%
o Grade of “C” is defined as  70% but < 80%
o Grade of “D” is defined as  60% but < 70%
o Grade of “Not Passed” as < 60%
Classroom Policies:
1. Late work/Testing: No extensions on the completion and submission of
homework or repeat exams are allowed.
2. Attendance policy: Students are required to attend all class sessions, although
it is understood that an unexpected circumstance may arise. After one “excused”
absence, the student may be dismissed from the learning program. If any
commitments arise, please contact the instructors as soon as possible.
3. Etiquette: Respect for fellow students and instructors is necessary by arriving
promptly to the learning program. Also all students are asked to turn off cell
phones during class to minimize distractions.
Condensed Course Outline:

Introduction to Scribing and the American Health Care System
o Course expectations – attendance, grading, syllabus, goals of the class
o What is a scribe?
o Health care system overview – members of the Emergency Medicine Team
o Basic “dos and do nots” in medicine

What Does Medical Scribing Entail?
o Basic patient encounter flow
o Example of a patient encounter
o Concepts and principles of an EMR and patient records
o Safety
o Regulatory compliance
o HIPPA
o ICD and CPT coding
o Codes of safe practice
o Clinical communication
o Professionalism

Upholding Quality and Efficiency of Patient Care
o Patient satisfaction
o Clinical conflict resolution
o Thinking like and emergency medicine physician
o Scribe responsibilities to the physician

The Language of Scribing
 Medical terminology and vocabulary
o Anatomy and physiology
o Radiology and Lab work
o Medications
 Components of a chart
o General overview
o Subjective
 HPI – PQRST
 Past Medical history
 Allergies
 Medications
 Social history
 Family history
 Past surgical history
o Objective
 Physical exam
o Assessment and plan
 Medical decision making
 Initial impression
 Differential Diagnosis
 Plan
 Results
 Consults
 Reassessment
 Disposition
o Special components of a chart
 Procedures
 Critical care time
 Observation time
 Discharge

The Electronic Medical Record
o Basics of EPIC, where to find prior labs, radiology studies, and notes
o Dot phrases
o Walk through of a basic patient case

Main Focus: Practicing Medical Scribing with Patient Cases, including:
o Chest pain
o Admitting someone to the observation unit
o Shortness of breath – asthma patient
o Abdominal pain
o Back pain
o Vaginal bleeding in pregnancy
o Orthopedic patient
o Procedural sedation
o Pediatric fever
o Altered mental status
Students with Documented Disabilities:
Students who may need an academic accommodation based on the impact of a disability
must initiate the request with the Office of Accessible Education (OAE). Professional
staff will evaluate the request with required documentation, recommend reasonable
accommodations, and prepare an Accommodation Letter for faculty dated in the current
quarter in which the request is made. Students should contact the OAE as soon as
possible since timely notice is needed to coordinate accommodations. The OAE is
located at 563 Salvatierra Walk, and can be reached at:
 Phone number: (650) 723-1066
 URL: http://studentaffairs.stanford.edu/oae