Portland Community College | Portland, Oregon

Upon completion of the course students should be able to:

• Demonstrate computer skills, scribing techniques, correct usage of ophthalmic terminology, and an ability to navigate electronic health records.
• Correct written documentation in an electronic health record. 
• Demonstrate appropriate oral skills frequently used in ophthalmology. 

Simulated practice in an EHR platform, lectures, written reports, online video resources or articles, terminology quizzes and scribing activities.

Identify the different components of the medical record, describe the standards for maintaining medical records in ophthalmology

Describe the major medical insurance programs and explain how to complete an insurance claim form using the Current Procedural Terminology (CPT) manual to code for procedures and services and the International Classification of Diseases (ICD-10-CM) manual to code for diagnoses

Describe the typical electronic health record (EHR) system, summarize the categories of data maintained on this type of system, and outline standard processes involved with entering, storing, manipulating, and retrieving patient information

Summarize the portions of the HIPAA Privacy Rule dealing with protected health information (PHI), confidentiality, and disclosure, and describe the circumstances under which information may be released without patient consent

Navigate cloud-based EMR software systems and use them to enter new patient information, encounter notes, physician information, insurance claims, and charting information

Practice ophthalmic terminology in regards to technician scribing through EHR simulation