Transcript Document
Week 8 Oncology MR260 Medical Transcription II Welcome to Week 8! • Agenda: – Reading • Chapter 18 in Medical Transcription Fundamentals • Read part of Chapter 16 in the Book of Style – Transcription assignments on MTClient – Editing Exercise MTClient • Any problems with MTClient • Please send me an email if you do [email protected] Hints • Sixteen minutes of a 30- minute appointment were spent in counseling and coordination of care. • Instead of • 16 minutes of a 30- minute appointment were spent in counseling and coordination of care. • Thank you instead of Thanks • Quotations = exactly what the doctor says…. Even if grammar is not correct – only time allowed contractions… • No contractions – don’t = do not, I’m = I am Websites • http://www.mtdaily.com/mt1/samplerad.html • http://www.mtsamples.com/site/pages/browse.asp?type=96Hematology%20-%20Oncology • https://sites.google.com/site/medicaltranscriptionsamples/hematologyoncology-medical-transcription-consultation-sample • http://medical-transcription-samplereports.blogspot.com/2011/03/hematology-oncology-consultation.html • http://mtdesk.com/Sample+Reports+for+Medical+Transcriptionists • http://onelook.com/ Oncology Can you trust a spellchecker to catch every error? A spellchecker found no errors in this discharge summary, but we found 29 mistakes. How many can you find? Oncology This 25-year-old Caucasian male was assaulted to days prior to admission. He developed paraorbital edema and diplopia at lateral gaze. He was seen in follow up in the office until the swelling subsided at which time it was felt that he had a below out fracture. Xrays confirmed this. He was admited four a pin reduction and end terminal fixation of the fracture. Past history was remarkable for seizure this order and a lung history of parental and/or all drug abuse. Physical exam revealed a well-developed while nourished male. There were no fresh tract marks. The right orbit was ecchymotic with the creased range of motion. The intraorbital nerve appeared in tack. The heart an lungs were otherwise with abnormal limits. The patient was taken for surgery where intraorbital and called well-luck incisions were made. A tap door-type fracture was noted at the flour of the orbit. This was reduced and backing was placed in the right max cilia to stabilize the re-duction. Postoperatively the patient did quit well. He required methadone for T myelograms. He was discharged to be followed in the clinic four-pack removal. Oncology This 25-year-old Caucasian male was assaulted (1) 2 days prior to admission. He developed (2) periorbital edema and diplopia at lateral gaze. He was seen in (3) followup in the office until the swelling (4) subsided at which time it was felt that he had a (5) blow-out fracture. X-rays confirmed this. He was admitted (6) for (7) open reduction and (8) internal fixation of the fracture. Past history was remarkable for seizure (9) disorder and a (10) long history of (11) parenteral (12) and oral drug abuse. Physical exam revealed a well-developed (13) well-nourished male. There were no fresh (14) track marks. The right orbit was ecchymotic with (15) decreased range of motion. The (16) infraorbital nerve appeared (17) intact. The heart (18) and lungs were otherwise (19) within normal limits. The patient was taken for surgery where (20) infraorbital and (21) Caldwell-Luc incisions were made. A (22) trapdoor-type fracture was noted at the (23) floor of the orbit. This was reduced and (24) packing was placed in the right (25) maxilla to stabilize the (26) reduction. Postoperatively the patient did (27) quite well. He required methadone (28) 40 mg. He was discharged to be followed in the clinic (29) for pack removal. . Oncology Instructions: The following is an excerpt of a discharge summary on an obstetrical patient. There are 12 errors consisting of homonyms, misspellings, and mishears in the report below. All the errors are words (not grammar or punctuation). Can you find the errors? Oncology CONDIITON ON DISCHARGE The patients being sent home two day in stable condition. Her vital signs are stabile. The patient is afebrile, having good urine output, and she had unspontaneous bowl movement yesterday. Lochias scant. She is on unusual diet, and she has no subjected complaints. The patient was very complaint with all advise given. The patient is in stable condition, in acute distress. . Oncology (1) CONDITION ON DISCHARGE The (2) patient is being sent home (3) today in stable condition. Her vital signs are (4) stable. The patient is afebrile, having good urine output, and she had (5) one spontaneous (6) bowel movement yesterday. (7) Lochia is scant. She is on (8) usual diet, and she has no (9) subjective complaints. The patient was very (10) compliant with all (11) advice given. The patient is in stable condition, in (12) no acute distress. . So long – See you next week! • Let me know if you have any problems with MTClient • No Discussion!! • Assignments • Editing – please review slowly • Have a great week!