February 2, 2023

Assistant in Medicine Course for Medical Students (Year 2 and above)

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Welcome! This interactive course will introduce you the role of medical scribes, and teach you how to function in a clinical environment as a documentation expert! This streamlined course builds on prior knowledge from your medical school studies, and it is designed to teach you the skills and techniques of robust and professional medical documentation. You will be expected to utilise your understanding of medical body systems (anatomy, pathophysiology), terminology & abbreviations and even pharmacology. You'll review a standard medical chart structure (SOAP format), and put all your knowledge into action as you "up-skill" on writing medical notes and functioning as an assistant to the physicians. 

As a scribe, your main purpose is to document everything relating to patient care. You'll act as a personal assistant to the doctors, to make their life easy and organised. Scribes are invaluable in improving efficiency and work flow patterns of doctors, and streamlining the patient journey. As an intern you will be documenting your own interviews, examinations and medical decision making - but as a scribe you get to see if first hand, learn from experienced doctors and get prepared for your own career.

The course will review and utilise medical vocabulary, but there will be many terms, abbreviations and phrases that are new to you. You'll need to make a conscious effort to look up EVERY new word or abbreviation as you progress, to ensure you are building up your own knowledge bank which will make dictation much easier. We will review the SOAP format of medical charts, how to order and documentation investigations, the basics of clinical letter and referral writing, and the scope of practice for a scribe. 

By the end, you will know how to complete a comprehensive medical record on behalf of any doctor with whom you work.  Furthermore, you’ll get advanced skills in medical documentation that will be invaluable as you progress to being a doctor yourself.

Here is a quick video to give you an insight into course:


Being medical students, you have probably already invested in the book Clinical Examination” by Nicholas Talley and Simon O’Connor. If not, we encourage you to add it to your library. It is invaluable in your career as a doctor and it will be helpful as you work through the course. Chapters 1 and 2 are particularly helpful in understanding the principles of good history taking, and Chapter 3 is a nice introduction into the general observations in a physical exam. 

The other text you will need is Mastering Medical Terminology, 3rd Edition Walker et al. It is written in British English, which is relevant for may medical terms (eg ECG versus EKG). It is a great reference for you as a medical scribe and also as a medical student. There will be references made to the text, and activities for completion. Please purchase an eBook or hardcopy, or borrow one for the duration of the course.

Course Content:

  • Overview of the Scribe Role
  • Importance of Medical Documentation
  • Privacy and Confidentiality
  • Health information and privacy act
  • Medical word building, terminology and abbreviations
  • Purpose of structure in a medical chart
  • SOAP, SOCRATES and symptom descriptors
  • How to document the HPI and PEx in real time
  • Ordering investigations and documenting results
  • Writing referrals

There is a mix of learning styles including:

  • Self-paced learning modules
  • Interactive audio and visual activities 
  • Written assignments with model answers
  • Case studies
  • Mock and patient videos for real-time scribe experience

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