BLANCHE ETTINGER, Ed.D. Bronx Community College of the City University of New York

Transcription

1 BLANCHE ETTINGER, Ed.D. Bronx Community College of the City University of New York ALICE G. ETTINGER, RN, MSN, CPNP Division of Pediatric Hematology-Oncology Saint Peter s University Hospital, New Brunswick, New Jersey

2 Brief Contents Part I Preparing to Transcribe 1 Chapter 1 The World of Medical Transcription 3 Chapter 2 Medical Terminology Review 39 Chapter 3 Perfecting Your Editing Skills 73 Part II Transcribing for the Specialties 123 Chapter 4 Dermatology 125 Chapter 5 Ophthalmology 149 Chapter 6 Otorhinolaryngology (ENT) 173 Chapter 7 Pulmonology 199 Chapter 8 Cardiology 225 Chapter 9 Gastroenterology 251 Chapter 10 Obstetrics and Gynecology 277 Chapter 11 Urology and Nephrology 303 Chapter 12 Orthopedics 331 Chapter 13 Neurology 355 Chapter 14 Hematology-Oncology 383 Chapter 15 Immunology 409 Appendix A Endocrinology Job Simulation 437 Appendix B Medical Transcriptionist Job Search 439 Appendix C Common Laboratory Values 443 Appendix D Common Drugs 447 Appendix E Abbreviations and Symbols 457 BRIEF CONTENTS iii

3 Contents Part I Preparing to Transcribe 1 Chapter 1 The World of Medical Transcription 3 Overview of the Profession 4 Growth in Medical Transcription 4 Employment Opportunities 5 The Medical Transcriptionist s Role in Patient Care 5 Personal Attributes of the Medical Transcriptionist 6 Required Knowledge and Skills 7 Professional Certification 8 Professional Principles of Transcription 8 Increase Speed While Striving for Accuracy 8 Maintain Confidentiality 9 Follow Ethical Guidelines 9 Appreciate Cultural Diversity 10 Getting Started 11 Transcription Equipment 11 Earphones 11 Foot Pedal 11 Transcriber Features Tapes Voice/Speech Recognition Systems 13 Transcription Ergonomics 14 Eyes 14 Ears 14 Hands and Wrists 15 Posture 15 Lifestyle Changes 15 Using Reference Materials 15 Medical Dictionary 15 Drug Book 16 Medical Style Guide 16 Medical Word Book/Medical Phrase Index 16 Abbreviations and Acronyms Reference 16 Medical Equipment/Surgical Words Book 16 Laboratory Word Book 16 Eponym Book 16 Online Resources 16 Nonmedical References 17 Transcribing, Proofreading, and Editing Tips 17 The Transcription Process 17 Editing Documents from Dictation 18 Dealing with Jargon and Clipped Sentences 19 Styles of Writing 20 Dealing with Dictator Accents 21 Proofreading Methods 21 Evaluating Your Work 21 Working with Medical Records 23 Medical Record Formats 23 Problem Oriented Medical Record 23 Narrative-Style Charting 26 How Records Are Used 26 Legal Issues Surrounding Medical Records 26 Retention 26 Ownership of Document and Content 26 Release of Information 26 Legal Terms Regarding Release of Information 27 Important Components of Medical Records 27 History and Physical 28 Operative Report 29 Discharge Summary 29 Chart Note 29 Consultation Request or Letter 29 Radiology Report 29 Pathology Report 29 Autopsy Report 29 Guidelines for Preparing and Managing Medical Records 29 Using Templates 33 Chapter 2 Medical Terminology Review 39 Word Parts and How They Are Combined 40 Root Words and Combining Forms 40 Prefixes 40 Suffixes 40 Suggestions for Learning Medical Terms 47 Anatomic Terms That Map the Human Body 51 Levels of Organization 51 Cells 52 Tissues 53 Organs 54 Body Systems 54 Body Cavities and Regions 54 Divisions of the Spinal Column Diagnostic Terms to Assess the Human Body Directional and Positional Terms 59 Directional Planes 60 Movement Terms 62 Combining Forms Referring to Color 62 Pain Assessment 64 Medical Imaging Terms 64 Radiology 65 Fluoroscopy 66 Sonography 66 Computed Tomography 66 Magnetic Resonance Imaging 67 Chapter 3 Perfecting Your Editing Skills 73 Repairing Sentence Fragments and Run-On Sentences 74 What Is a Sentence? 74 Fragments 75 Run-On Sentences 75 Exceptions to the Rules in Medical Reports 76 Creating Subject-Verb Agreement 77 Complicating Factor: Inverted Order Sentences 78 Complicating Factor: Intervening Words and Phrases 79 Creating Agreement Between Pronouns and Antecedents 80 Pronouns as Subject or Object 81 Pronoun/Subject Agreement 81 Who versus Whom 81 Myself, Himself, and Other Reflexive Pronouns 82 Punctuating with Commas, Semicolons, and Colons 83 Commas: To Introduce 83 Commas: To Separate 84 Commas: To Enclose 85 Semicolons 85 Colons 86 Using Dashes, Quotation Marks, and Parentheses 88 Dashes 88 Quotation Marks 88 Parentheses 90 Using Modifiers to Achieve Correct Meaning 91 Related Words Should Be Placed Together 91 Misplaced or Dangling Modifiers 92 Forming Plurals 93 Rules for Plural Forms 93 Other Plural Forms 94 iv CONTENTS

4 Forming Plural Abbreviations 94 Plural Numbers and Units of Measure 95 Using Capitals Correctly 96 Proper Nouns 96 Abbreviations 97 Acronyms 98 Eponyms 99 Drug Allergies 99 Document Elements 100 Using Numbers in Word or Figure Form 102 First Word of a Sentence 102 Units of Measurement and Lab Values 102 Similar Types of Data 103 Dates 103 Age 103 Time 104 Money 104 Measurements, Mathematical Expressions, and Symbols 104 Decimals and Fractions Using Abbreviations Correctly To Abbreviate or Not to Abbreviate 109 Units of Measure 110 Punctuation with Abbreviations 110 Plural Abbreviations 111 Abbreviations That Have Multiple Meanings 111 Shorthand Dictation 111 Using Apostrophes Correctly 112 Contractions 112 Years 113 Possessive Forms 113 Plurals 114 Using Hyphens Correctly 116 Compound Adjectives 116 Prefixes and Suffixes 117 Suspended Hyphens 119 Specific Words 119 Other Uses of the Hyphen 120 Part II Transcribing for the Specialties 123 Chapter 4 Dermatology 125 Exploring Dermatology 126 Structure and Function 126 Physical Assessment 127 Diseases and Conditions 127 Common Tests and Surgical Procedures 129 Building Language Skills 130 Building Transcription Skills 140 The Office Note 140 Preparing to Transcribe 140 Patient Studies 142 Assessing Transcription Skills 147 Using Medical References 147 Making Expert Decisions 148 Transcribing Professional Documents 148 Chapter 5 Ophthalmology 149 Exploring Ophthalmology 150 Structure and Function 150 Physical Assessment 151 Diseases and Conditions 152 Common Tests and Surgical Procedures 153 Building Language Skills 154 Building Transcription Skills 163 The Consultation Letter/Report 163 Required Headings/Content 163 Contents Turnaround Time 163 Preparing to Transcribe 164 Patient Studies 164 Assessing Transcription Skills 171 Using Medical References 171 Making Expert Decisions 172 Transcribing Professional Documents 172 Chapter 6 Otorhinolaryngology (ENT) 173 Exploring Otorhinolaryngology (ENT) 174 Structure and Function 174 Physical Assessment 176 Diseases and Conditions 178 Common Tests and Surgical Procedures 179 Building Language Skills 180 Building Transcription Skills 189 The Operative Report 189 Required Headings/Content 189 Turnaround Time 189 Preparing to Transcribe 190 Patient Studies Assessing Transcription Skills Using Medical References 197 Making Expert Decisions 198 Transcribing Professional Documents 198 Chapter 7 Pulmonology 199 Exploring Pulmonology 200 Structure and Function 200 Physical Assessment 201 Diseases and Conditions 202 Common Tests and Surgical Procedures 203 Building Language Skills 204 Building Transcription Skills 214 The Discharge Summary 214 Required Headings/Content 214 Turnaround Time 214 Preparing to Transcribe 217 Patient Studies 217 Assessing Transcription Skills 223 Using Medical References 223 Making Expert Decisions 224 Transcribing Professional Documents 224 Chapter 8 Cardiology 225 Exploring Cardiology 226 Structure and Function 226 Physical Assessment 228 Diseases and Conditions 229 Common Tests and Surgical Procedures 229 Building Language Skills 231 Building Transcription Skills 241 The Radiology Report 241 Required Headings/Content 241 Turnaround Time 241 Preparing to Transcribe 241 Patient Studies 242 Assessing Transcription Skills 248 Using Medical References 248 Making Expert Decisions 249 Transcribing Professional Documents 249 Chapter 9 Gastroenterology 251 Exploring Gastroenterology 252 Structure and Function 252 Physical Assessment 255 Diseases and Conditions 256 CONTENTS v

5 vi CONTENTS Contents Common Tests and Surgical Procedures 256 Building Language Skills 258 Building Transcription Skills 269 The Pathology Report 269 Required Headings/Content 269 Turnaround Time 269 Preparing to Transcribe 269 Patient Studies 269 Assessing Transcription Skills 275 Using Medical References 275 Making Expert Decisions 276 Transcribing Professional Documents 276 Chapter 10 Obstetrics and Gynecology 277 Exploring Obstetrics and Gynecology 277 Structure and Function 278 Physical Assessment 279 Diseases and Conditions 280 Common Tests and Surgical Procedures 281 Building Language Skills 283 Building Transcription Skills The Labor and Delivery Report Required Headings/Content 293 Turnaround Time 293 Preparing to Transcribe 293 Patient Studies 293 Assessing Transcription Skills 301 Using Medical References 301 Making Expert Decisions 302 Transcribing Professional Documents 302 Chapter 11 Urology and Nephrology 303 Exploring Urology and Nephrology 304 Structure and Function 304 Physical Assessment 306 Diseases and Conditions 307 Common Tests and Surgical Procedures 307 Building Language Skills 308 Building Transcription Skills 317 The History and Physical 317 Required Headings/Content 317 Turnaround Time 322 Preparing to Transcribe 323 Patient Studies 323 Assessing Transcription Skills 329 Using Medical References 329 Making Expert Decisions 330 Transcribing Professional Documents 330 Chapter 12 Orthopedics 331 Exploring Orthopedics 332 Structure and Function 332 Physical Assessment 336 Diseases, Conditions, and Injuries 337 Common Tests and Surgical Procedures 337 Building Language Skills 339 Building Transcription Skills 347 The Emergency Department Report 347 Required Headings/Content 347 Turnaround Time 347 Preparing to Transcribe 350 Patient Studies 350 Assessing Transcription Skills 353 Using Medical References 353 Making Expert Decisions 354 Transcribing Professional Documents 354 Chapter 13 Neurology 355 Exploring Neurology 356 Structure and Function 358 Physical Assessment 358 Diseases and Conditions 361 Common Tests and Surgical Procedures 362 Building Language Skills 363 Building Transcription Skills 373 The Neuropsychological Evaluation 373 Required Headings/Content 373 Turnaround Time 373 Preparing to Transcribe 373 Patient Studies 373 Assessing Transcription Skills 381 Using Medical References 381 Making Expert Decisions 382 Transcribing Professional Documents 382 Chapter 14 Hematology-Oncology 383 Exploring Hematology-Oncology Structure and Function Physical Assessment 389 Hematologic Diseases and Conditions 389 Oncologic Diseases and Conditions 389 Common Tests and Surgical Procedures 390 Building Language Skills 391 Building Transcription Skills 400 The Outpatient Visit Report 400 Required Headings/Content 400 Turnaround Time 400 Preparing to Transcribe 400 Patient Studies 403 Assessing Transcription Skills 407 Using Medical References 407 Making Expert Decisions 408 Transcribing Professional Documents 408 Chapter 15 Immunology 409 Exploring Immunology 410 Structure and Function 410 Physical Assessment 411 Diseases and Conditions 412 Common Tests and Surgical Procedures 413 Building Language Skills 414 Building Transcription Skills 422 The Autopsy Report 422 Required Headings/Content 422 Turnaround Time 423 Preparing to Transcribe 423 Patient Studies 423 Assessing Transcription Skills 435 Using Medical References 435 Making Expert Decisions 436 Transcribing Professional Documents 436 Appendix A Endocrinology Job Simulation 437 Appendix B Medical Transcriptionist Job Search 439 Appendix C Common Laboratory Values 443 Appendix D Common Drugs 447 Appendix E Abbreviations and Symbols 457 Glossary 465 Index 495