Transcript Document

MR250 MEDICAL
TRANSCRIPTION I
Week 5
Instructor:
Amber Krasny MBA, CPC, CMRS
MT Notebook…
• Please make yourself a notebook
either hard copy or digital for things
that you’ll want to remember.
• Once you have reviewed your
dictation make note of the
corrections in there for future
reference.
• Put tabs in sections like
punctuation/grammar,
medications, abbreviations,
formatting etc.
Quick Quiz…
• What is the #1 misspelled
word in the English
Language?
• Why do you think that is?
• What can you do to
remember which one to
use?
ANSWER KEY
• Its
• Because it is confused with the
contraction it’s (it is).
• Read the sentence by using “it
is” in it and see if that fits. If not
than it is the possessive pronoun
“its.”
• I had a doll it’s hair was red.
Read aloud: I had a doll it is hair
was red.???NO
• So it must be “its” not “it’s.”
Questions from Gilmore…Chapter 5
Mechanics of Editing
Fill in the blanks…
1. …improper use of __________ and ________
is not only a __________ to the reader, but it
can also ______ the ________ of a ________.
2. A carelessly ________ medical _________not
only makes a bad ____________, but in the
case of __________reports, might _________
a patient’s _________.
ANSWER KEY
1. …improper use of punctuation and
grammar is not only a distraction to the
reader, but it can also change the
meaning of a sentence.
2. A carelessly proofread medical
document not only makes a bad
impression, but in the case of medical
reports, might endanger a patient’s
health.
Grammar Review
• Sentences are the building blocks
of writing. An independent clause
can function as a complete
sentence; it consists of a subject
(s)and a verb (v)and expresses a
complete thought.
– The patient (s) left (v) the clinic.
• Most sentences contain more than
a simple subject and verb.
– The patient’s blood (s) work was (v)
completed, and he (s) left (v) the clinic
for home.
Sentence Fragment
Sentence fragments are
acceptable in medical
transcription. Transcribe what is
dictated—full sentence,
fragment, or a list.
1. Fragments are often seen in
which types of reports?
2. Give me an example from the
three areas listed in your
textbook.
ANSWER KEY Cont.
• They are particularly common
in the physical exam, lab results,
or review of systems sections of
reports, even when complete
sentences are used in the same
sections or other parts of the
report.
– LUNGS: Clear.
– Blood pressure: 120/80
– MEDICATIONS: Coumadin 5 mg
per day, Isordil and Valium
– White blood cells 17,000.
Subject Verb Agreement
Subjects must agree with their verbs
in terms of number (singular or
plural) and person (first, second,
or third).
Why are these examples below
incorrect?
1. The review of systems are
negative.
2. There has been several scans
showing masses in the breast.
3. Each of the nurses have a cell
phone.
ANSWER KEY
1. The review of systems are negative.
The review of systems is negative.
The subject is “review,” not systems.
TIP: Eliminate the prepositional phrase
“of systems” and see how it sounds.
2. There has been several scans
showing masses in the breast.
There have been several scans
showing masses in the breast.
The subject and verb have been
reversed in this sentence, it is
actually “scans”
ANSWER KEY Cont.
3.
Each of the nurses have a cell phone.
Each of the nurses has a cell phone.
Many indefinite pronouns are singular i.e.
another, anybody, each, either, every,
etc.
Rule 1001.b Gregg Reference Manual:
“although “s” or “es” added to a noun
indicates the plural form, “s” or “es”
added to a verb indicates the 3rd person
singular.
The price seems reasonable. (Singular)
The prices seem reasonable. (plural)
Periods and more…
Frequently physicians will dictate
punctuation, do not confuse that with
a word to be typed into the
sentence.
The period can be dictated
specifically as “period,” or “full stop.”
Parentheses in full or shortened.
Not: Paren it is my personal opinion that other
areas may show a more severe dysplasia
paren.
But: (It is my personal opinion that other areas
may show a more severe dysplasia.)
Periods Cont.
1. Give me an example of a
period being used in a
drug-related abbreviation
or unit of measure.
2. Do you use a period(s)
here: “MD”? If so, where. If
not, why not?
3. For additional information
see The Book of Style pages
104-108 and page 230.
Colon
1. Capitalize the word following the colon
if it is normally capitalized. If it follows a
section or subsection heading, or if the
list or series that follows the colon
includes one or more complete
sentences. Do not capitalize the word
following the colon if the items are
separated by commas.
2. Give me an example for each of
these rules.
ANSWER KEY
1. The patient’s past history is as
follows: omeprazole, metoprolol,
and Xanax.
2. PAST HISTORY: Negative.
3. Chest x-ray revealed the
following: No cardiomegaly. No
pulmonary infiltrates. Normal
cardiac silhouette.
4. Chest x-ray the following: Chest xray revealed the following: no
cardiomegaly, no pulmonary
infiltrates, and normal cardiac
silhouette.
Apostrophe
An apostrophe (‘) is used to
indicate the possessive case of
nouns, to form some plurals of
words, or to denote omitted
letters or numbers in contractions.
1. Give me an example of an
apostrophe used to show the
plural of letters, symbols, lower
case abbreviations, and/or
single-digit numbers or terms.
2. Do I use it for upper case
abbreviations also? Give me an
example.
ANSWER KEY
1. ab’s, rbc’s 4 x 4’s, serial 7’s
2. RBCs, EKGs, PVCs
Adjectives
•
Use a hyphen to join compound
adjectives.
–
–
–
a well-developed, well-nourished
female
A high-risk patient
24-year-old white male
• DO NOT use a hyphen to join most
prefixes, including the prefix
“non.”
• Give me some examples of the
above words that DO NOT need
a hyphen.
ANSWER KEY
• Nonweightbearing,
preoperative, postoperative,
outpatient, nontender,
noncontributory,
extraocular, nearsighted,
bimanual….
Capitalization
1. Capitalize brand names of drugs
but not generic names. Give me
some examples.
2. What are the rules for capitalizing
the names of bacteria. Give me
examples.
3. Do not capitalize words that
indicate classification or
categories except those
containing a proper noun. Give
me examples.
ANSWER KEY
1.
Xanax (alprazolam), Lipitor
(atorvastatin), Tylenol (acetaminophen)
2. Capitalize the genus but not the
species name for bacteria. If the genus
is abbreviated, capitalize the one-letter
abbreviation, followed by a period.
–
Staphylococcus aureus
–
E. coli
3. Examples: grade 1, stage III, Duke’s
class A.
Proofreading
• On page 117 and 118
there are some great ideas
for effective proofreading.
• Share your 3 favorites with
the class.
The End…
• Well that’s all for today!
• Thanks for joining us.
• I hope you learned something to
help you in your new transcription
career!
• Remember to get all of your
assignments in on time! TATS are
important!!
• See you next week! Same time—
same.