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1 Instructions In this course, you learn to transcribe and edit reports. When transcribing a report, you listen to dictation and create the entire document. When editing a report, the speech recognition software attempts to create the document, which is then edited by the transcriptionist listening to the report and correcting mistakes. This course introduces you to editing software called ChartScript. However, we are offering an alternative to using the ChartScript software that still allows you to experience editing reports while reviewing a raw report and listening to the dictation. When you reach the Speech Recognition Editing lesson, please use the materials here to complete the Practice Reports and Quizzes. Beginning with Lesson 51, you will read each lesson in full, but use the instructions included in the SRT Trainer for the editing steps. First, read the Editing Software Overview that follows so that you have a better understanding of the process. Editing Software Overview If editing is part of your transcription position, you ll have an SRT editing program on your computer that houses report audio files and SR reports. In order to simulate this without having an SRT editing program, you will access report audio files and SR reports. You ll open each report, click on the audio file that corresponds with the report and edit the document. Let s walk through what you would see if you were using an SRT editing program. First, you d download the program and login. Once you pull up your first job, you are presented with a voice file of dictation and a document of text. You will first fill in or confirm some patient information at the top of the report. You will press the play area of the foot pedal and listen to the information the dictator gives, such as the patient name, spelling, unit number or date of birth. This helps you verify that the voice file information matches the report and the header information is correct. You ll use the functions in the editing program to adjust the audio speed and volume to your liking. You will listen, read along and identify areas of the report that the SRT didn t interpret correctly. This includes misspelling of English words, medical words, incorrect punctuation and grammar, as well as extra or missing text. You ll pause the audio using your foot pedal and place your typing cursor at each point in the report where a change needs to be made to make your edits. This way you can delete and add elements as needed in order to make the report read correctly. After practice, you ll be able to listen and make edits at the same time, which will increase your editing speed. You may pause several times to look up terms and verify spellings. You ll use references to check information either books or electronic references. You may have access to a database of patient information to help verify laboratory values and medications and other terms that are unclear in the dictation. You will use the Internet to help find more obscure or new terms, which you will then verify in medical references. All of these duties are part of the typical transcribing and editing process CD03A-94 Page 1

2 When you complete the job, you check the report in for a supervisor to review it. Once it s reviewed, it s uploaded to the dictating clinician in the electronic health record (EHR) for an electronic signature. The record will be available to all of the patient s caregivers, and it will present as a completed document to all readers. Advanced Editing Details For your SRT lessons, you will have access to the audio for each report and a raw report produced by SRT software that you will edit. For each of the practice reports, you will also have access to footnoted Answer Keys so you can check your work. You will see that the dates dictated and transcribed are left blank in the Answer Keys. You should fill these in with the current dates just as you have on previous reports, and add your initials after the doctor s initials on each report. You will follow the same basic formatting guidelines for your SRT reports as you have used in the rest of Course Five. Continue to use Times New Roman font in size 12 with single line spacing, and continue to use 1-inch margins all around the page. Identifying information, including the patient name and number, the doctor s name and report title, are included on the first page of the report only, and the signature line, dates dictated and transcribed and initials are included at the end of each report. When you come to the end of a page, keep typing through the page break as though it didn t exist. Do not leave a gap at the end of the first page; the text should flow continuously from one page onto the next. Finally, there is no identifying information at the top of the second page in SRT reports. About Your Resources The instructions, audio, raw reports and Answer Keys are available online for you through the Student Site. To access these resources, log into the Student Site, and click on Download Course Materials. As previously mentioned, in order to practice editing without having an SRT program, you will use the following steps for each report that you edit: 1. Save the audio for the reports onto your computer. 2. Open Express Scribe and load the audio for your lesson into Express Scribe. 3. Save the raw reports onto your computer. 4. Open your word processing program that you have on your computer and open the raw report in that program. 5. Use Express Scribe and your foot pedal to play the audio. 6. Read the raw report while listening to the audio. Edit when you find SRT errors, and correct any format or punctuation errors you find. 7. When you ve completed the editing, you will need to save your report. When you open a rough or raw report from SRT, the first sentence or two is usually demographic information (called the preamble). This information usually includes the patient name and number, the doctor s name and the type of report that is being dictated. This information will be edited into the identifying information section of your report CD03A-94 Page 2

3 Steps to Take The lessons where you will edit SRT reports are Lessons 51, 52, 53, 54 and 55. You should read through each of the lessons. When you get to the Practice Reports and Quiz, you will refer to the instructions found here instead of the instructions in your materials. First, you will open the file for the lesson Instructions and read through the materials that replace your Practice Report or Quiz. Then, you will follow the instructions to open and load the audio, as well as the raw report. Let s walk through the process with Jan Keating. To edit the Chart Note for Jan Keating #JK030609CN you follow these steps. 1. Locate the audio for this report and load it into Express Scribe. 2. Locate the raw report and open it in your word processing program CD03A-94 Page 3

4 The following is the raw SR report for Jan Keating: 3. Play the audio file in Express Scribe using your foot pedal and follow along in the raw report. According to Rule 1, you do not use abbreviations in the ASSESSMENT; therefore, you ll research the meaning for SLE and RA to write out the acronyms. You will use a comma to separate items in a series according to Rule 26. This rule will apply to the list of studies in the PLAN. Finally, the comment This is the end of this chart note is not part of the report and should be deleted. 4. Research to confirm the correct term and spelling. Proofread your work. 5. To check your work, open the footnoted Answer Key for this report and compare it to the report that you edited. Remember to check any unfamiliar terminology for spelling and context as well as reviewing for correct format and punctuation for each report CD03A-94 Page 4

5 Your final product should look like the following: Practice Reports Your course materials direct you to use ChartScript to complete the Practice Reports and Quizzes; alternatively, you can choose to complete the lessons using our SRT editing process as outlined. When you are directed to use ChartScript in your lesson materials, simply access the file with the same heading and follow the instructions using the SRT. If you have questions on the process, please contact your instructor for assistance CD03A-94 Page 5

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