This is not the first time I have touched on this subject nor will it be the last, I am sure. Students MUST READ AND FOLLOW INSTRUCTIONS! I cannot stress this enough.
As an instructor, I cannot tell you how much time and frustration would be saved if instructions were read and followed.
Many times our students refer to the dreaded “do not use” list, the “dangerous abbreviation” list, or the “ISMP” list.
I am here to tell you that 99% of those abbreviations are use on a daily basis when working as a medical transcriptionist.
So, please disregard the lists and go ahead and use those abbreviations.
In some professions guessing or winging it is acceptable. This is definitely NOT the case when working as a medical transcriptionist. Lives can be at stake, literally. If you guess at a medication or the dosage you could be endangering that patient.
Guessing is never okay and is a sure-fire way to getting yourself in the unemployment line. It is not only lazy but dangerous. If you cannot understand a word or sentence you will list that on the log to be checked out by your proofreader and/or the dictator. Please do not guess.
A word to the wise!
A common frustruation with students learning medical transcription is the sometimes conflicting information received. Students learn from their assigned books, the Internet, and other resources. Sometimes this information can be different but yet still correct.
Quite often there can be more than one right answer but usually just one preferred way. At Med Workshops we teach using various materials but also geared towards making sure the students are learning the preferred way for internship and the employers we will be placing them with.
Bottom line–flexibility is key!
Sjögren syndrome. Pronounced shor’gren. This has been a stumper for both newbie and seasoned medical transcriptionists to verify spelling on.
This is an autoimmune disorder in which immune cells attack and destroy the exocrine glands that produce saliva and tears.
It was named after Henrik Sjögren (1899-1986), a Swedish opthalmologist who first described it.
It is estimated to touch as many as 4 million people in the United States, which makes it the second most common autoimmune rheumatic disease.
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.
Pfannenstiel incision, yet another exasperating word for the medical transcriptionist. Why? Because the “p” is silent.
This is a type of incision that allows access to the abdomen. This incision is a slightly curved cut right above the pubic symphysis. The usual reasons for this incision are hernia repair and obstetric delivery. Named after the surname of a German gynecologist, Hermann Johannes Pfannenstiel.
Numbers are an ongoing source of frustration for medical transcriptionists.
The AAMT is in the process of changing the rules for numbers. At the present time the safest bet is to use numerals. Some items could go either way, but the numbers that should ALWAYS be typed as numbers would be ages, units of measure, numbers 10 and higher, etc. An exception to this would be two numbers in a row, such as twelve 4-0 Ethilon sutures. That is the correct way. You would not type 12 4-0 as that is confusing to the eye.
But, no matter what is considered the correct way, the provider’s preference trumps everything else.
How do I know when to use lie versus lay? This is a question many medical transcriptionists, and actually the general population, have queried.
Lay requires an object and lie does not. Example would be “you lie down on the exam table” and “you lay the baby down”, with the baby being the object.
These, of course, are present tense. Past tense gets a bit trickier and we will cover that in a future article.
Ptosis. This word has caused many newbie medical transcriptionists untold frustration. The reason for this is it is pronounced toe-sis. The “p” is silent.
Ptosis is a condition of the eye where the eyelid droops due to muscle weakness. It can affect one or both eyes and is more common in the elderly population but can be congenital. It can also occur because of cranial nerve damage, cerebrovascular accidents, and other neurologic disorders.
Word of the week: Ptosis.