Transcript Chapter 4 - Transcription Process

Chapter 4 –
Transcription Process
Prepared by:
Arlene N. Baratang
Objectives
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To define what transcription process is;
To learn the sound of medical transcription; and,
To be able to use different reference materials
such as word books, pharmaceutical references,
abbreviation books, style guides, anatomy and
physiology textbooks, English dictionary,
electronic reference materials, online resources
and other reference sources.
Transcription Process
The transcription process is the
integration of listening, keyboarding,
and understanding the dictation.
Your goal is to synchronize your
fingers, foot, and brain into one fluid
motion.
Sound of Medical Transcription
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The dictation has a terse, staccato
sound, and the dictator has a
tendency to abbreviate words and
condense sentences wherever
possible.
Using Reference Materials
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Medical Dictionary
 Unlike an English dictionary, medical words are listed
under the governing noun in a medical dictionary, with
multiple word terms listed as subentries.
 Each entry includes the word origin, plural form,
preferred spellings, cross reference, and
pronounciation guides.
 Two popular medical dictionaries are:
 Dorland’s Illustrated Medical Dictionary
 Stedman’s Medical Dictionary
(Reference materials..)
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Word Books
– such as surgery, radiology, cardiology,
and laboratory word books are designed as alphabetic lists
of medical words without definitions to finds terms
quicker.
 Be aware there is usually no indication that a word
may have a sound-alike word.
 Word books do not differentiate between preferred and
alternative acceptable spellings.
 Use critical thinking and word discrimination skills.
 The “correct” medical term must make sense in the
context of the report.
(Reference materials..)
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Pharmaceutical References
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Drug books contain alphabetical indexing, a description
of the drug, method of administration and dosage,
classification, indications for use and contradiction, and
the differentiation between generic and brand names.
Drug books are updated monthly, quarterly or
annually.
Popular drug books:
 The American Drug Book
 The Physician’s Desk Reference (PDR), and
 Physician’s GenRx
(Reference materials..)
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Abbreviation Books
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Acronyms and abbreviations are found in their own
word books.
Eponyms are adjectives taken from a surname and
used to describe diseases, instruments, procedures
and so on.
Entries are listed alphabetically by the adjective, not
the noun.
 Example: Valsalva maneuver under Valsalva
(adjective) not under maneuver (noun).
(Reference materials..)
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Styles Guides
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Used for consistency, accuracy and clarity in
preparing medical documents.
Resulted in the development of many different
yet acceptable manuals of style.
To determine proper editing, punctuation, and
grammar guidelines.
Respected manual of styles: AAMT Book of Style
for Medical Transcription, and the American
Medical Association Manual of Style
(Reference materials..)
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Anatomy and Physiology Textbooks
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Useful reference materials that can help
clarify your understanding of the content of
the dictation.
These textbooks discuss body structure
and function in detail.
It may include disease processes and
disorders.
(Reference materials..)
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English Dictionary
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Helpful in finding synonyms, antonyms,
grammar, spellings, pronunciations,
hyphenations, and definitions.
Medical transcriptionist must posses a good
command of the English language.
(Reference materials..)
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Electronic Reference Materials
 Two distinctive electronic references:
 medical dictionaries
 Medical spellers
- Both are compatible with popular word
processing software packages.

Electronic medical spellers can work with the existing
spell checker and can be customized to include
troublesome medical terms.
(Reference materials..)
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Online Resources
 Where information on new medical
techniques, procedures, drugs, transcription
products, among others can be obtained.
 Can enter a chat room with medical
transcriptionists where you can obtain advice
about word usage, spelling, etc.
 Key in the string medical transcription to
obtain numerous entries.
(Reference materials..)
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Homonyms or sound-like words are
prime examples where the computer
will not recognize the word as
misspelled or suggest a substitute word.
On-line Resources
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www.angelfire.com:MT Daily
www.aamt.org/aamt: AAMT Web page
www2.ncbi.nlm.nih.gov/medline/query_
form.html:Medline website
www.hpisum.com:Perspectives on the
Medical Transcription Profession
www.www,com/kamt:Keeping Abreast
of Medical Transcription
Other Reference Sources
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Telephone books
Current magazines
American Hospital Association Guide to
the Health Care Field
American Medical Association
Membership Directory
Word Search
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Find a medical word under its main
entry.
Diseases may be searched under
syndromes.
Procedures may be searched under
operations
Word Search
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Medical terms are formed by back
formation, such as a noun used as
a verb.
Medical terms composed of a
noun and adjective, i.e. eponyms
(Valsalva maneuver, Foley
catheter), are found under the
noun.
Homonyms and Sound-alike
Medical Terms
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Afferent (n) – moving toward the center
Efferent (n) – moving away from the
center.
Anuresis (n) – retention of urine in the
bladder
Enuresis (n) – involuntary discharge of
urine
Homonyms and Sound-alike
Medical Terms
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Atopic (adj) – displaced
Atrophic (adj) – decrease in the size of
a normally developed organ or tissue.
Ectopic (adj) – located away from
normal position.
Aural (adj) – pertaining to the ear.
Oral (adj) – pertaining to the mouth.
Pointers for Beginnners
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Listen to the entire document for
any instructions, corrections, and
comments.
Stop and start the audio tape as
often as desired.
Familiarize yourself with the
pronunciation and the meaning of
various words.
Pointers for Beginnners
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Take time to learn the fundamentals
of medical transcription.
The transcription process is to listen
to a block of dictation, stop, and
then accurately transcribe what you
have heard.
Think about what you are
transcribing.
Pointers for Beginnners
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Concentration will avoid errors of wrong word
choice and inconsistencies in text.
When in doubt about a word, phonetically
spell the word and either underscore or bold
the word to remind you to verify its meaning.
The dictator may repeat the words again, or
get a clue from the content of the report.
Pointers for Beginnners
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The final step is to proofread your
document, correct your errors, and
print the final document.
It may be helpful to retranscribe
(not retype) difficult reports to
strengthen your skills.
You will need the following:
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Computer with word processing software
package
Transcriber
Headset or earphones
Footpedal
Reference materials
Printer and paper
CD-ROM/flash drive with dictated materials
REFERENCES
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AAMT Book of Style for Medical
Transcription
American Medical Association Manual of
Style
Medical Transcription Guide Do’s and
Don’t’s