RHAB 340 – CRN 20192
Medical Terminology & Documentation
Spring 2012
Instructor: Autumn Bruton, MOT, OTR/L
Class time: On-Line Class
Location: On-Line
Office hours:
Office phone: 575-574-5171 or 575-574-5662
Email address: casselg@wnmu.edu or through our class email
Office Location: Watts Hall Room 120
Fax 575-575-5150
Course Description:
This writing intensive course offers the student an introductory experience in basic medical
terminology used in many areas of the health and rehabilitation sciences. The course also covers
various types of documentation used in the rehabilitation field including the SOAP format, narrative
note writing, evaluation and re-evaluation reports, treatment, progress and discharge notes. The
student will be familiar with documentation principles using the APA format used in manuscript
writings.
Schedule subject to change to meet the needs of the class
Required texts:
1. Medical Terminology Book:
E-Textbook: Scientific and Medical Terminology.
**Purchasing Your On-Line Textbook at: E-Textbook Website Address: www.wnmumedterm.com with
online final examination $99.95
**Optional Companion Textbook
Students who want to save time and ink in printing their own copies can contact:
Target Copy
1412 West University Avenue
Gainesville, Fla. 32603
E-mail Address: service@target-copy.com (352)376-3826
Or you can order the workbook on Amazon (Medical Terminology Author: Dr. Siegfried Fagerberg)
Note: The Optional Textbook/Workbook contains the following:
1. All lecture slides in chapters 1-4 (Basis of Medical Terminology)
2. All 1000 flash card Word Parts, Abbreviation and “Fill-In-The Blank” exercises chapter 5.
3. All 800 M/C chapter Tests and “Fill-In-The Blank” chapters 4 and 6-14.
2. Writing Manual:
American Psychological Association. (2009). APA publication manual. (6th ed.).
Washington DC: American Psychological Association.
3. Documentation textbook:
Borcherding,S & Morreale,M (2007) The OTA’s Guide to Writing SOAP Notes (2nd ed). Thorofare, NJ:
Slack Incorporated.
ISBN 978-1-55642-779-4
In addition to selected material from the text, students may be required to read and research other
outside resources or other materials from the Internet.
Course Objectives: By the end of the course the student will
Cognitive Domain
1. Develop and demonstrate an understanding of the medical vocabulary used in a wide variety of
health related settings.
2. Recognize the different types of documentation.
Affective Domain:
3. Appreciate and understand the purpose and necessity of professional communication, both
written and oral.
4. Respond to feedback in a positive manner.
5. Value and model reliable work and study habits.
Psychomotor Domain
6. Demonstrate beginning skills in written communication through the practice of proper
documentation using a variety of formats.
7. Demonstrate an understanding of documentation and its impact on medical reimbursement for
occupational therapy services.
8. Demonstrate an understanding of ethical and legal responsibilities of the documentation process,
including adhering to facility, local, state, and federal reimbursement agencies.
9. Show observation skills in writing and classroom activities.
10. Demonstrate an understanding of both oral and written communication skills.
11. Reiterate an understanding of correct APA format in manuscript (research) writing.
12. Demonstrate the ability to document occupational therapy services to ensure accountability of
service provision and to meet the standards for reimbursement of services by federal, state, private
pay, and third-party systems.
13. Demonstrate the ability to effectively interact through written, oral and nonverbal
communication with the family, client, significant others, colleagues, and the public in a
professionally acceptable manner.
Expectations:
1. The student will abide by all University policies as outlined in the University catalogue.
2. The student will abide by all departmental policies as outlined in the OTA student handbook.
3. The student will be respectful of others in the class, work cooperatively, and share responsibility
for classroom respectfulness (e.g. turning off cell phones, keeping the room clean and free of trash,
etc.).
4. If the student requires ADA accommodations, the student must identify him or her self by
contacting the Special Needs Office at 538-6498.
5. Late assignments and tests not completed on the scheduled day will lose 5% of the available
points for each day they are late. Unless prior arrangements have been made, assignments more
than a week late will not be accepted. If the student has not called in with an excused absence on
the day of a quiz, a make up quiz will not be given.
How this class will work:
This class is divided into three distinctly different modules:
1. APA style and research writing
2. Medical terminology
3. Documentation
APA research writing - The first module, APA style and research writing, the student will have
assigned readings and discussions. A review of literature research paper is required for this section
of the course, but will be due at the end of the semester, giving the student adequate time to
complete a comprehensive review of literature, write a summary of the findings using APA style,
and read peers’ papers.
Medical terminology-The second module is to be completed using the interactive workbook that
you purchased. This module consists of lectures, flashcards, and quizzes. Also, a comprehensive
final exam will be completed.
Documentation – The third module will focus on health related documentation. There will be
lectures, discussions, and quizzes assigned to assess student progress.
Evaluation methods
Assignments
Research Paper
APA Quiz
Medical Terminology
Workbook
Medical Term. Final Exam
Documentation Quizzes
*2 Quizzes at 5 points each*
On line discussion participation
*10 topics at 2 points each*
Total possible
Points
Grade Conversion
15
5
40
A = 89.6-100 points
B = 79.6-89.5 points
C = 69.6-79.5 points
10
10
D = 59.6-69.5 points
F = Less than 59.5
20
100