Archive for the ‘Editing and Proofreading’ Category

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Medical Transcription Tips

Monday, August 9th, 2010

Just a few odds and ends.

Most bacteria is italicized.

We do not use contractions  such as can’t or won’t. Type out the whole thing, cannot; will not, etc.

If the dictator starts a numbered list in the assessment, impression, or plan and goes to the next item without saying the number, go ahead and type in the number. 

If there are two numbers in a row such as twelve 4-0 Ethilon sutures, always have one of the numbers in digit format and the other one typed out. This helps to avoid confusion.

If the provider states an abbreviation, then type it as such, do not expand out. CABG would be typed just like that. Do not expand.  

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Working as a Medical Transcriptionist

Tuesday, August 3rd, 2010

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!

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Transcription Tips

Monday, July 19th, 2010

However. Just a quickie lesson on the punctuation that goes along with this word.

The word itself is never alone. It either has a semicolon or comma. If it is the first word in a sentence, there will be a comma after it. If in the middle of a sentence then either with a semicolon or comma before and then a comma afterwards.

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Transcription Formatting

Tuesday, June 29th, 2010

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.

Posted in Editing and Proofreading, Formatting, Newbie Medical Transcriptionists | No Comments »

Numbers in Medical Transcription

Tuesday, June 15th, 2010

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.

 

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Medical Transcription Grammar Tip

Thursday, June 10th, 2010

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.

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Medical Transcription English Rules

Thursday, May 20th, 2010

Why is “well-nourished Caucasian woman” acceptable but “Caucasian woman is well-nourished” not? It is because it all depends where the noun is. If the hyphenated words are before the noun, hyphen is fine; after the noun, no hyphen.  So, a “3 x 5-mm scar” is okay as well as “the scar is 3 x 5 mm” but “the scar is 3 x 5-mm” is not correct. One of the easier rules of this wonderful yet quite often complicated English language!

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Typing Medical Transcription

Wednesday, May 12th, 2010

Punctuation is everything…

An English professor wrote: “A woman without her man is nothing”on the chalkboard and asked his students to punctuate it correctly.

All of the males in the class wrote, “A woman, without her man, is nothing.”

All the females in the class wrote:   “A woman: without her, man is nothing.”

Does punctuation really matter? As this example proves, it really does! So many times we ask ourselves, should there be a comma there?  When do I use a semicolon? Does it really matter if I leave that colon out? As you can see just in this one example alone, yes, punctuation is very important as a simple comma or colon or any other form of punctuation can change the meaning of the entire sentence. 

To all you future MTs reading this, please take note!

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Learning Medical Transcription

Wednesday, May 12th, 2010

Is it follow-up, followup, or follow up? How can eight simple letters be so confusing? This simple word, or two, is responsible for many periods of ponderation. First and foremost, in the transcription field we no longer use follow-up. So, with that option eliminated let’s move on to the remaining two choices.  

Followup is a noun whereas follow up is an adjective. “The patient will schedule a followup” as opposed to “the patient will follow up”. One very easy way to remember which one to use is this simple rule: If you can put an “A” in front of the word then it would be followup; if not, then use follow up.  One less thing to wonder about!

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Working at Home as a Medical Transcriptionist

Sunday, May 9th, 2010

One of the biggest concerns of new MTs is “what do I do if I can’t hear or understand the dictator?” There is also the question of what to do if the MT thinks the provider/dictator is wrong, such as dictating the right leg was injured and then later in the chart note stating it was the left leg.

When actually working as an MT you will have a “Daily Log”. This is where you will track the patient’s name and date of service. It is also where you will note things such as if you cannot understand a word, you heard the word but cannot find it to verify spelling (this happens a lot with medications), contradictory information, or anything else you question. Research and using your references is a huge part of being a skilled MT, but when you have exhausted all avenues then you would note it on the log. You will turn this log in with your files and your proofreader will take it from there.

It is always a good day when you can turn in a blank log!

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