📘 CPMS™ Study Guide – Overview
The Certified Professional Medical Scribe (CPMS™) Study Guide prepares candidates
to support providers with high-quality clinical documentation and EHR navigation.
This guide is essential for anyone aiming to succeed on the CPMS™ exam and excel
in a scribe role within healthcare settings.
📚 Table of Contents & Topic Breakdown
1. Medical Scribe Fundamentals
Role of a medical scribe
Real-time documentation and provider support
Workflow and clinical efficiency
Professionalism and communication with the care team
2. Electronic Health Records (EHR)
Navigating common EHR systems (e.g., Epic, Cerner, Allscripts)
Accurately entering patient history, vitals, and orders
Templates, macros, and smart phrases
Documenting structured vs. unstructured data
Avoiding copy/paste errors and compliance risks
3. Medical Terminology & Anatomy
Word roots, prefixes, and suffixes
Common abbreviations used in documentation
Anatomy of all major body systems
Terminology by specialty (e.g., cardiology, orthopedics, gastroenterology)
4. Clinical Documentation Guidelines
History of Present Illness (HPI)
Review of Systems (ROS)
Physical exam documentation (normal and abnormal findings)
Assessment and Plan (A/P) notes
SOAP vs. other documentation styles
Avoiding subjective opinions and assumptions
5. Compliance & HIPAA
Legal responsibilities of a scribe
HIPAA and patient confidentiality
Access restrictions and audit trails
Ethical documentation and handling sensitive information
6. Medical Coding & Reimbursement Basics
Introduction to ICD-10-CM, CPT, and HCPCS
Understanding the role of coding in reimbursement
How documentation supports medical necessity
Recognizing coding-relevant details (e.g., laterality, severity)
7. Time Management & Efficiency
Real-time documentation tips
Multitasking with accuracy
Avoiding documentation backlogs
Supporting the provider’s workflow without interruptions
📝 Tips for CPMS™ Exam Preparation
Practice EHR charting using mock patient encounters
Study anatomy and terminology by body system
Review SOAP note templates
Understand basic ICD-10 and CPT code structure
Simulate timed documentation to improve efficiency
📘 Medical Scribe Principles
📍 Course Overview
This course introduces students to the essential principles and responsibilities of a
medical scribe, including documentation skills, provider communication,
compliance, medical terminology, and safety protocols. It is ideal for anyone
pursuing a clinical support role or preparing for the CPMS™ certification.
🧠 Learning Objectives
By the end of this course, you should be able to:
Understand basic medical terminology and anatomy.
Communicate effectively with healthcare providers.
Ensure HIPAA and compliance adherence.
Convert clinical statements into compliant medical documentation.
Understand documentation, coding, and billing basics.
Recognize the impact of quality measures on records.
Practice safety in clinical environments.
🩺 Section 1: Anatomy & Medical Terminology
Key Topics:
Word roots, prefixes, suffixes
Directional terms (anterior, posterior, etc.)
Body systems overview (cardiovascular, respiratory, digestive, etc.)
Common medical abbreviations
📝 Study Tips:
Flashcards for prefixes/suffixes
Label body diagrams for anatomy recall
Practice decoding medical terms
💬 Section 2: Provider Communication
Key Topics:
How to query providers for clarification
Presenting questions clearly and professionally
Documenting direct quotes and clarifications
📝 Study Tips:
Practice mock queries with sample provider notes
Use SBAR (Situation, Background, Assessment, Recommendation) for
structured communication
✅ Section 3: Compliance (Fraud, Abuse, HIPAA)
Key Topics:
Definitions of fraud and abuse (e.g., upcoding, unbundling)
HIPAA Privacy and Security Rules
Minimum necessary rule
Role of a scribe in safeguarding PHI (Protected Health Information)
📝 Study Tips:
Memorize HIPAA key points using a chart
Use case studies to identify compliance issues
📄 Section 4: Medical Record Documentation
Key Topics:
SOAP format (Subjective, Objective, Assessment, Plan)
Importance of accuracy, clarity, and completeness
Ancillary clinical indicators (labs, radiology, referrals)
Proper use of EMRs and templates
Error correction protocols (single line strikeout, date/time/initial)
Roles of clinical staff in documentation
📝 Study Tips:
Practice transcribing notes into the SOAP format
Identify incomplete or vague documentation in samples
Create a checklist of documentation do’s and don’ts
📊 Section 5: Quality Measures
Key Topics:
What is "Meaningful Use"?
Quality reporting metrics (e.g., smoking status, immunizations)
Impact of documentation on quality reporting and reimbursement
📝 Study Tips:
Learn 3–5 quality measures and how documentation supports them
Review provider incentive programs and their connection to EHR use
💸 Section 6: Coding and Billing Basics
Key Topics:
Difference between ICD-10-CM, CPT, and HCPCS Level II
Link between documentation and code selection
Role of scribes in supporting accurate coding through complete
documentation
📝 Study Tips:
Review common ICD/CPT codes by system (e.g., respiratory, cardiovascular)
Match example documentation with appropriate codes
Section 7: Safety Protocols
Key Topics:
Universal precautions
Bloodborne pathogens and PPE (Personal Protective Equipment)
Sterile field procedures
Scribe safety practices (e.g., hand hygiene, exposure protocols)
📝 Study Tips:
Memorize steps for proper PPE donning and doffing
Understand exposure response protocols (e.g., needle stick injury)
