2019 - 2020
Florida Department of Education
Curriculum Framework 

Program Title:	Medical Records Transcribing/Healthcare Documentation
Program Type:	Career Preparatory
Career Cluster:	Health Science

Career Certificate Program	
Program Number	H170506	
CIP Number	0351070701	
Grade Level	30, 31	
Standard Length	1200 hours	
Teacher Certification	Refer to the Program Structure section.	
CTSO	HOSA: Future Health Professionals	
SOC Codes (all applicable) 	29-2099 Health Technologists and Technicians, All Other
31-9094 Medical Transcriptionists	
CTE Program Resources 	http://www.fldoe.org/academics/career-adult-edu/career-tech-edu/program-resources.stml	
Basic Skills Level	Mathematics:	9
Language:	11
Reading:	11	

Purpose

This program offers a sequence of courses that provides coherent and rigorous content aligned with challenging academic standards and relevant technical knowledge and skills needed to prepare for further education and careers in the Health Science career cluster; provides technical skill proficiency, and includes competency-based applied learning that contributes to the academic knowledge, higher-order reasoning and problem-solving skills, work attitudes, general employability skills, technical skills, and occupation-specific skills, and knowledge of all aspects of Health Science career cluster. 

This program is designed to prepare students for employment as SOC 31-9094 Medical Transcriptionists.

The content includes but is not limited to medical terminology, anatomy and physiology, grammar and punctuation, health care delivery systems, health information services, ethical and legal responsibilities, safety/security procedures, word processing/ transcription skills and employability skills.  

Additional Information relevant to this Career and Technical Education (CTE) program is provided at the end of this document.

Program Structure

This program is a planned sequence of instruction consisting of 2 occupational completion points.

This program is comprised of courses which have been assigned course numbers in the SCNS (Statewide Course Numbering System) in accordance with Section 1007.24 (1), F.S.  Career and Technical credit shall be awarded to the student on a transcript in accordance with Section 1001.44(3) (b), F.S.

To teach the courses listed below, instructors must hold at least one of the teacher certifications indicated for that course.

The following table illustrates the postsecondary program structure:

OCP	Course Number	Course Title	Teacher Certification	Length	SOC Code	
A	HIM0009	Introduction to Health Information Technology 	MED RECTEC 7G 
MED TRANS 7G 
MED ASST 7G	90 hours	29-2099	
B	HIM0074	Medical Transcriber 1		370 hours	31-9094
	
	HIM0075	Medical Transcriber 2 		370 hours		
	HIM0081	Medical Transcriber 3		370 hours		

Common Career Technical Core – Career Ready Practices

Career Ready Practices describe the career-ready skills that educators should seek to develop in their students.  These practices are not exclusive to a Career Pathway, program of study, discipline or level of education.  Career Ready Practices should be taught and reinforced in all career exploration and preparation programs with increasingly higher levels of complexity and expectation as a student advances through a program of study. 

1. Act as a responsible and contributing citizen and employee. 

2. Apply appropriate academic and technical skills. 

3. Attend to personal health and financial well-being. 

4. Communicate clearly, effectively and with reason. 

5. Consider the environmental, social and economic impacts of decisions. 

6. Demonstrate creativity and innovation. 

7. Employ valid and reliable research strategies. 

8. Utilize critical thinking to make sense of problems and persevere in solving them. 

9. Model integrity, ethical leadership and effective management. 

10. Plan education and career path aligned to personal goals. 

11. Use technology to enhance productivity. 

12. Work productively in teams while using cultural/global competence. 

Standards

After successfully completing this program, the student will be able to perform the following:

01.0	Demonstrate an understanding of healthcare organizations and health occupations.
02.0	Demonstrate the ability to communicate and use interpersonal skills effectively.
03.0	Explore health informatics as an allied health profession.
04.0	Demonstrate an understanding of health data concepts.
05.0	Identify the functions of a health record.
06.0	Demonstrate an understanding of Health Information Technology.
07.0	Discuss classification systems, clinical vocabularies and terminologies.
08.0	Evaluate ethical issues in Health Information Professions.
09.0	Demonstrate compliance with laws, regulations, and standards that impact healthcare.
10.0	Apply policies, regulations, and standards to the management of information associated with treatment, payment, and operations (TPO). 
11.0	Demonstrate computer knowledge and skills.
12.0	Demonstrate employability skills.
13.0	Utilize appropriate medical and scientific terminology.
14.0	Apply concepts of disease, diagnosis, and treatment of the human body.
15.0	Apply rules of English grammar and punctuation.
16.0	Utilize medical references.
17.0	Apply healthcare documentation technology.
18.0	Perform functions specific to the medical transcription/healthcare documentation specialist.
19.0	Perform proficiently in the application of healthcare documentation/transcribing concepts and skills through practical lab experiences.
20.0	

2019 - 2020
Florida Department of Education
Student Performance Standards

Program Title:  Medical Records Transcribing/Healthcare Documentation
Career Certificate Program Number:  H170506

Course Number: HIM0009
Occupational Completion Point: A
Introduction to Health Information Technology – 90 Hours – SOC Code 29-2099	
01.0	Demonstrate an understanding of the healthcare organizations and health occupations. – The student will be able to:	
01.01	Discuss the evolution of healthcare.	
01.02	Demonstrate an understanding of the infrastructure of healthcare in the United States.	
01.03	Discuss healthcare regulatory agencies and organizations.	
01.04	Recognize levels of education, credentialing requirements, employment opportunities, workplace environments, and career growth potential.	
01.05	Differentiate the roles of various providers and disciplines throughout the continuum of healthcare and respond to their information needs. 	
02.0	Demonstrate the ability to communicate and use interpersonal skills effectively. – The student will be able to:	
02.01	Develop basic speaking and active listening skills with meaningful feedback. 	
02.02	Develop basic observational skills and related documentation strategies in written and oral form.	
02.03	Identify characteristics of successful and unsuccessful communication including barriers. 	
02.04	Respond to verbal and non-verbal cues. 	
02.05	Compose written communication including emails using correct spelling, grammar, formatting and confidentiality. 	
02.06	Demonstrate ability to create professional correspondence using appropriate email practices and etiquette. 	
02.07	Use appropriate medical terminology and abbreviations. 	
02.08	Model the importance of courtesy and respect for patients and other healthcare workers and maintain good interpersonal relationships. 	
02.09	Provide health information education to internal/external stakeholders.	
02.10	Adapt communication skills to varied levels of understanding and cultural orientation including diverse age, cultural, economic, ethnic, and religious groups. 	
02.11	Distinguish between and identify subjective and objective information. 	
03.0	Explore health information as an allied health profession. – The student will be able to:	
03.01	Discuss the history of health information management.	
03.02	Discuss the professional opportunities within the health information professions.	
03.03	Demonstrate knowledge of professional associations applicable to the field of health information.	
04.0	Demonstrate an understanding of health data concepts. – The student will be able to:	
04.01	Describe the various uses of primary and secondary health data and data sets. 	
04.02	Identify various characteristics of health data quality and standards.	
05.0	Identify the functions of a health record. – The student will be able to:	
05.01	Demonstrate an understanding of the various formats of the health record.	
05.02	Explain the various uses of a health information as it relates to treatment, payment, and operations (TPO). 	
06.0	Demonstrate an understanding of Health Information Technology. – The student will be able to:	
06.01	Discuss how changing regulations and technology impact the health information field.	
06.02	Interpret information from health information systems and applications in healthcare.	
06.03	Demonstrate an understanding of creation, use, storage, retrieval, and exchange of health data.	
07.0	Discuss classification systems, clinical vocabularies and terminologies. – The student will be able to:	
07.01	Explain the use of classification systems, clinical vocabularies, and terminologies as they relate to Health Information Management and nomenclatures. 	
08.0	Evaluate ethical issues in Health Information Professions. – The student will be able to:	
08.01	Describe the code of ethics consistent with healthcare occupations.	
08.02	Analyze ethical issues related to health information.	
08.03	Manage ethical issues related to coding and billing/ healthcare documentation.	
09.0	Demonstrate compliance with laws, regulations, and standards that impact healthcare. – The student will be able to:	
09.01	Promote the importance of maintaining ethical and legal standards in compilation and usage of health information. 	
09.02	Identify all laws and standards that impact health information including the Health Insurance Portability and Accountability Act (HIPAA). 	
09.03	Explain the composition of the legal health record.	
09.04	Apply health information policies and procedures for privacy, confidentiality, and security. 	
09.05	Articulate legal terms and processes that impact healthcare. 	
10.0	Apply policies, regulations, and standards to the management of information associated with treatment, payment, and operations (TPO). – The student will be able to:	
10.01	Describe how to adapt workflow necessitated by regulatory change. 	
10.02	Demonstrate knowledge of policies and procedures for access and disclosure of protected health information to authorized users.	
10.03	Adhere to appropriate and applicable accrediting agency guidelines.	
11.0	Demonstrate computer knowledge and skills. – The student will be able to:	
11.01	Demonstrate the ability to create, manage, organize, attach, and retrieve files.	
11.02	Demonstrate ability to connect to and perform research on the internet by identifying reliable reputable websites.	
11.03	Demonstrate proficiency in word processing, spreadsheets, and presentation software.	
11.04	Demonstrate the ability to install software programs. 	
11.05	Demonstrate knowledge of safe computer practices and security procedures including but not limited to encryption, passwords and biometrics.	
12.0	Demonstrate employability skills. – The student will be able to:	
12.01	Identify and exemplify personal traits or attitudes desirable in a member of the healthcare team. 	
12.02	Model professional standards of healthcare workers as they apply to hygiene, dress, language, confidentiality and behavior (i.e. courtesy and self-introductions).	
12.03	Identify documents that may be required when applying for a job. 	
12.04	Perform the process to obtain employment: job search, cover letter, resume, application, and thank you letter. 	
	
Course Number: HIM0074
Occupational Completion Point: B 
Medical Transcriber 1 – 370 Hours – SOC Code 31-9094	
13.0	Utilize appropriate medical and scientific terminology. – The student will be able to:	
13.01	Spell, define and pronounce medical words and their components.	
13.02	Define and use medical abbreviations, brief forms, acronyms, eponyms, and foreign words and phrases commonly used in healthcare practice.	
13.03	Identify and use the medical terminology related to the structure and function of the human body.	
13.04	Identify, pronounce, spell, and define pharmacological terminology.	
13.05	Distinguish between or among medical homophones (sound-alikes), commonly confused medical terms, and synonyms.	
14.0	Apply concepts of disease, diagnosis, and treatment of the human body. – The student will be able to:	
14.01	Identify and explain structure and function of the human body in health and in disease.	
14.02	Identify disorders and treatments of the human body.	
14.03	Identify and explain procedures and technologies, imaging, laboratory, pathology, and their application to diseases and disorders. 	
14.04	Demonstrate knowledge of pharmacology to include indications and contraindications, dosage, methods of administration, interactions and side effects. 	
14.05	Organize surgical procedures and other interventional diagnostic and treatment modalities by specialty, indications or related diagnoses, technique, and typical findings.	
15.0	Apply rules of English grammar and punctuation. – The student will be able to:	
15.01	Recognize and use the principal parts of speech.	
15.02	Recognize and use punctuation marks.	
15.03	Apply rules of numerical expression.	
15.04	Apply rules of capitalization.	
15.05	Define and use abbreviations.	
15.06	Demonstrate ability to spell words in common usage. 	
15.07	Evaluate and use reliable resources for research and practice.	
15.08	Apply correct medical style as defined by authorities (i.e. AHDI Book of style, AMA Manual of Style).	
15.09	Edit and proofread healthcare documentation.	
15.10	Recognize and use report formats.	
16.0	Utilize medical references. – The student will be able to:	
16.01	Utilize medical dictionaries and specialty word books.	
16.02	Utilize trade, generic and chemical drug names utilizing reference sources.	
16.03	Utilize diagnostic test terminology.	
16.04	Utilize appropriate resources located on the internet.	
	
Course Number: HIM0075
Occupational Completion Point: B 
Medical Transcriber 2 – 370 Hours – SOC Code 31-9094	
17.0	Apply healthcare documentation technology. – The student will be able to: 	
17.01	Demonstrate keyboarding skills with an awareness of productivity and accuracy standards and definitions.	
17.02	Demonstrate use of transcription, dictation, and speech recognition technology. 	
17.03	Accurately transcribe and/or edit a required minimum number of reports to include history and physical, consultations, discharge summaries, operative reports and special reports, applying competencies specified in the areas of English language, medical knowledge, technology, healthcare documentation, and professional practice. 	
17.04	Demonstrate the ability to proofread and correct transcribed healthcare documents, including using critical thinking and editing skills.	
17.05	Identify inconsistencies, discrepancies, and inaccuracies in healthcare dictation while transcribing/editing, without altering the meaning of the content.	
17.06	Demonstrate advanced use of word processing programs, including commands for editing, file organization, and retrieval.	
17.07	Demonstrate knowledge of abbreviation expanders and other productivity-enhancing software.	
17.08	Demonstrate a general knowledge of health information systems including the functions related to dictation/transcription integration, editing, and common terminology. 	
18.0	Perform functions specific to the medical transcriptionist/ healthcare documentation specialist. – The student will be able to:	
18.01	Promote common health information policies and procedures for security specific to the role of the medical transcriptionist/ healthcare documentation specialist. 	
18.02	Demonstrate workstation ergonomics specific to the medical transcriptionist/ healthcare documentation specialist  	
18.03	Demonstrate an awareness of the opportunities in medical transcription/healthcare documentation and related careers and the importance of professional development. 	
18.04	Explain the importance of maintaining workstation security and safeguarding protected health information (PHI).	
18.05	Explain the scope of work of the medical transcriptionist/healthcare documentation specialist.	
18.06	Discuss the code of ethics of the Association for Healthcare Documentation Integrity (AHDI).	
	
Course Number: HIM0081
Occupational Completion Point: B 
Medical Transcriber 3 – 370 Hours – SOC Code 31-9094	
19.0	Perform proficiently in the application of healthcare documentation/transcribing concepts and skills through practical lab experiences. – The 
student will: 	
           36.01 Model the role and responsibilities of the healthcare documentation transcription specialists.	
           36.02 Apply knowledge and skills related to speech recognition, dictation, documentation standards, technology, and transcription.	
           36.03 Perform real-world applications of healthcare documentation/transcription principles and best practices. 	
           36.04 Analyze errors and devise corrective strategies. 	
           36.05 Transcribe and/or edit a minimum 2100 minutes of authentic clinician-generated documentation. 	

Additional Information

Laboratory Activities

Laboratory investigations that include scientific inquiry, research, measurement, problem solving, emerging technologies, tools and equipment, as well as, experimental, quality, and safety procedures are an integral part of this career and technical program/course. Laboratory investigations benefit all students by developing an understanding of the complexity and ambiguity of empirical work, as well as the skills required to manage, operate, calibrate and troubleshoot equipment/tools used to make observations. Students understand measurement error; and have the skills to aggregate, interpret, and present the resulting data. Equipment and supplies should be provided to enhance hands-on experiences for students. 

Special Notes

For those programs preparing students for the Registered Healthcare Documentation Specialist industry certification through Association for the Healthcare Documentation Integrity (AHDI) the model curriculum of the AHDI should be used to properly prepare students for this examination. Industry Certification is voluntary and is sponsored by the AHDI. 

4230 Kiernan Avenue
Suite 130
Modesto, CA 95356
Phone: Toll Free (800) 982-2182 - Direct (209) 527-9620
Fax: 209-527-9633.  Web site:  http://www.ahdionline.org/ E-mail:  ahdi@ahdionline.org 
Students should be encouraged to become members of their professional organization, and participate in the state/local chapter activities. 

The program should prepare the graduate to take the national examination to become a Registered Medical Transcriptionist. Certification is voluntary and is sponsored by the Association for Healthcare Documentation Integrity (AHDI). http://www.ahdionline.org/

Outcomes 01- 12 are referred to as the Health Information Technology core and do not have to be completed if the students has previously completed the core in another program at any level. The Core should be taken first or concurrently with the first course in the program.

MyCareerShines is an interactive resource to assist students in identifying their ideal career and to enhance preparation for employment. Teachers are encouraged to integrate this resource into the program curriculum to meet the employability goals for each student.  Access MyCareerShines by visiting: www.mycareershines.org.

Career and Technical Student Organization (CTSO)

HOSA: Future Health Professionals is the intercurricular career and technical student organization providing leadership training and reinforcing specific career and technical skills.  Career and Technical Student Organizations provide activities for students as an integral part of the instruction offered.  

Cooperative Training – OJT

On-the-job training is appropriate but not required for this program.  Whenever offered, the rules, guidelines, and requirements specified in the OJT framework apply. 

Basic Skills 

In a Career Certificate Program offered for 450 hours or more, in accordance with Rule 6A-10.040, F.A.C., the minimum basic skills grade levels required for postsecondary adult career and technical students to complete this program are:  Mathematics 9, Language 11, and Reading 11.  These grade level numbers correspond to a grade equivalent score obtained on a state designated basic skills examination.  

Adult students with disabilities, as defined in Section 1004.02(7), Florida Statutes, may be exempted from meeting the Basic Skills requirements (Rule 6A-10.040).  Students served in exceptional student education (except gifted) as defined in s. 1003.01(3) (a), F.S., may also be exempted from meeting the Basic Skills requirement.  Each school district and Florida College must adopt a policy addressing procedures for exempting eligible students with disabilities from the Basic Skills requirement as permitted in Section 1004.91(3), F.S.

Students who possess a college degree at the Associate of Applied Science level or higher; who have completed or are exempt from the college entry-level examination; or who have passed a state, national, or industry licensure exam are exempt from meeting the Basic Skills requirement (Rule 6A-10.040, F.A.C.)  Exemptions from state, national or industry licensure are limited to the certifications listed on the Basic Skills and Licensure Exemption List which may be accessed from the CTE Program Resources page.

Accommodations

Federal and state legislation requires the provision of accommodations for students with disabilities to meet individual needs and ensure equal access. Postsecondary students with disabilities must self-identify, present documentation, request accommodations if needed, and develop a plan with their counselor and/or instructors. Accommodations received in postsecondary education may differ from those received in secondary education. Accommodations change the way the student is instructed. Students with disabilities may need accommodations in such areas as instructional methods and materials, assignments and assessments, time demands and schedules, learning environment, assistive technology and special communication systems. Documentation of the accommodations requested and provided should be maintained in a confidential file.

Note: postsecondary curriculum and regulated secondary programs cannot be modified.

Additional Resources

For additional information regarding articulation agreements, Bright Futures Scholarships, Fine Arts/Practical Arts Credit and Equivalent Mathematics and Equally Rigorous Science Courses please refer to:
http://www.fldoe.org/academics/career-adult-edu/career-tech-edu/program-resources.stml