Transcript MR260 Seminar Week 3 Student Version

MR260 Medical Transcription II
Week 3-Chapter 5
“Family Practice
& Critical Thinking”
Essentials of Medical Transcription
Instructor: Amber Krasny MBA, CPC,CMRS
What You need for this class…
• Both textbooks:
Essentials of Medical Transcription, A
Modular Approach, Destafano &
Federman, Second Edition
AAMT Book of Style for Medical
Transcription
Any other resource books you may
have available such as medical
dictionary, PDR, Merck Manual, etc.
How the class will work…
• This is an open book Seminar.
• Be prepared to respond to the questions on
each slide.
• Be prepared to share your thoughts with the
other class participants.
• After the questions slide you will see an answer
slide so you can check to see how you did.
Is everyone ready?
Critical Thinking Skills
 Learning to be a critical thinker is imperative in our
business.
 Developing critical thinking techniques ensures the
accuracy and validity of your documents.
 Using critical thinking techniques will help you find
the answers to all the questions that will come up
as you are transcribing.
Characteristics of a Critical
Thinker
• Raymond S. Nickerson (1987),
an authority on critical thinking,
characterizes a good critical
thinker in terms of knowledge,
abilities, attitudes, and habitual
ways of behaving. Here are
some of the characteristics of
such a thinker.
http://www.freeinquiry.com/critical-thinking.html
Nickerson’s Partial List…
Uses evidence skillfully and impartially.
Distinguishes between logically valid and
invalid inferences [conclusions].
Can learn independently and has an
abiding interest in doing so.
Is aware of the fact that one's
understanding is always limited, often
much more so than would be apparent to
one with a non-inquiring attitude [mind].
A Fun Definition of Critical
Thinking
• Paul, Binker, Adamson, and Martin
(1989)
• "the art of thinking about your
thinking while you are thinking in
order to make your thinking better:
more clear, more accurate, or
more defensible.“
• This is called “metacognating,” or
thinking about what you are
thinking about.
Critical Thinking Cont.
• Can you find the word “metacognating”
in or through any of your resources?
• If so, where and what is the definition
that they give?
• Can you give me an example of when
you have caught yourself
metacognating?
4 Steps to Critical Thinking
1. Identify the elements of your document
a. Body system and/or specialty
b. type of document
c. report headings, paragraph content, and the
other sentences in the paragraph that you have
already transcribed
d. Find the diagnosis or procedure.
e. Use any other information you may have on
hand, such as the medical record or previous
reports.
4 Steps to Critical Thinking
2. Evaluate your assumptions about
those elements
a. Does this word, test, etc. belong in
or with this body system,
procedure, operation, diagnosis?
3. Judge your choices probability or
acceptability of being right.
4 Steps to Critical Thinking Cont.
4. Evaluate your choices by asking: “With what I
already know, which is the most probable or
likely to be correct, and why?”
Group Discussion
• Finally, After going through
this and none of the things
seem right, or you can’t
find an answer what do you
do?
NO, don’t throw
your books out
the window!!
Now here are some opportunities
to use what you just learned.
Exercise
• The next few slides have
sentences to review.
• Using the Critical Thinking Model
we just discussed choose the
correct word(s) for the sentence.
H&P Family Practice
• “She noted that his BP drops at times at home
going into the hundred sycosis/systolic/stasis
range.”
• Hypertension and angina
parous/pectoris/pectineal. MI 3 months ago.
• Medications:
• Lipitor/lisinpril 10 m.g. daily
• Lopressor/lorazepam 100 m.g. BID
Answer the multiple choice
questions below:
1. Accumulation of fluid and cellular debris in the
tissues:
1.
2.
3.
4.
Exdate
Exudate
Edema
Exdema
2. Inflammation of the mucous membrane of the
nose
1.
2.
3.
4.
Mucosa
Mucos
Rhinitis
rinitis
Group Discussion
• How did you do?
• Give me some idea of why you
chose one thing over the
other, especially in
question 1 where the two
words exudate and edema are
so close?
Chart Note Family Practice
• SUBJECTIVE: The patient comes in still
complaining of mid-upper gastric pain. She
denies any hematemesis/chemotaxis or
melena/heloma.
• OBJECTIVE: Her skin pallor/pallium is normal.
The abdomen is soft, slightly tender in the
epigastric/epiglottis region. There is no
rigidity/depilatory or rebound.
Group Discussion
How did you do? Give me some
idea of why you chose one
thing over the other?
Will this lesson help you in
the future? How?
The End
• Well that’s all for tonight! Next week we’ll
do some more metacognating!!
• Thanks for joining us. I hope you learned
something to help you in your transcription
career.
• I’m feeling a little bewitched
after this class!
•
See you next week! Same time—same
place!