How do I know when to use italics?
Most often when working as a medical transcriptionist, the only time you would italicize anything would be if it was a bacteria such as Chlamydia or Enteroccocus.
Only use italics for the singular form of the word, not for the plural form.
A lot of newbie medical transcriptionists have problems deciding where to insert certain items in the chart note.
Usually the provider dictates the note specifically as he/she wants it typed out. However, there are the occasional providers who bounce around or don’t say exactly where to type things.
One confusing aspect for the newbie is history of present illness (or HPI) and review of systems (or ROS). The HPI is where things are listed that pertain only to what the chief complaint is. The ROS would be anything that pertains to the actual systems of the body such as fever, chills, nausea, etc.
These two headings can seem one and the same to the unexperienced MT but indeed they are not.
As you can probably imagine, we frequently get questions related to Medical Transcription grammar and format rules. Most of our training is by textbook, but many of our examples are taken from our employers. One of our objectives is to introduce you to variety in Medical Transcription styles so you can adapt more easily once you are employed.
Grammar won’t make or break your career as an MT. The reason is that style can be very subjective. It’s good to learn the basics and then be flexible when you go to work with your future employer – they will determine “house rules” which override all other sources of information.
Stressing over these issues is counter productive because there isn’t a universal answer in many cases. There can be two correct answers or even more! It is a much better idea to move along more quickly and keep the Big Picture in mind; you don’t have to be perfect. The Big Picture goal is to be employed so you can use your flexible skills.
You can use these quizzes to learn several ways of doing things. The AAMT Book of Style is excellent and is our style bible, but it is trumped by “house rules” or “doctor rules”.
Question- Help, I’m a little stuck. I’ve just started Medical Transcription Typing 1 and I don’t understand the dictator and am having trouble understanding the format. Please give me a pointer or two so I can get unstuck.
Answer- I transcribed the dermatology report you were asking about. Here is what it should look like. Keep in mind as I wrote earlier- Do Not Stress- you are just getting started. Too much stress is counter productive. New students often get stuck; don’t feel bad.
I transcribed the dermatology report you were asking about. Here is what it should look like. This will all come in time. Trying too hard can be counter productive. After a couple of months, you will go back to reports like this and think it is a piece of cake. Hope this helps. Have a great holiday!
Report:
CHIEF COMPLAINT: Laceration, right index finger.
HISTORY: This 28-year-old woman was at work one hour ago when she cut the tip of her right index finger on a meat slicer accidentally. She has no other injury.
PHYSICAL EXAMINATION: The patient has a 1-inch linear longitudinal laceration over the volar aspect of the distal phalanx, right index finger. The patient has good sensation and vascular refill distally. There is no deformity or limitation of motion.
DIAGNOSIS: Acute laceration, right index finger.
Let’s talk employment assessment. While we are school, we are also a placement company. Our employers are looking for grads with attitudes that match their aptitude- if they can find them, which is not always easy. To that end, you should know that a synopsis of your emails and contacts are recorded in your overall assessment. The employer wishes to know as much about the student as possible. They are hoping to find a graduate who is good with detail, gets good grades and has a positive, flexible attitude.
Sometimes when a student is feeling frustrated, it’s easy to send out an email expressing that, but remember that a synopsis of your emails may be reviewed by your future employer.
In the end, MTs work for Doctors and other dictators. The Clinic and the person dictating together create what is known as “house rules”. Even though there is a preferred way of transcribing, the doctor may ask for something which is not correct and the MT still has to type it as dictated. THIS IS THE REASON that employers look for attention to detail AND flexibility. Those MTs who have developed both of these skills do the best in this field and command the highest pay—and isn’t that what we are all looking for in the long run?
MANY students find inconsistencies in the study and practice of MT and are frustrated by them. Please be aware that this is all part of learning to be flexible and adapting to changing situations while at work in Medical Transcription.