Archive for June, 2010

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 »

Transcription Definition

Monday, June 28th, 2010

Isn’t Latin, the core of the English language, supposed to make it easier to understand words? Maybe not.

Scler or sclero. This prefix means either hardness or the sclera of the eye. Two totally different meanings. Yet another item in the long list of medical words that make you wonder who really is responsible for our confusion!

Posted in Anatomy and Physiology, Terminology | No Comments »

Medical Transcription Word of the Week

Friday, June 25th, 2010

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.

Posted in Newbie Medical Transcriptionists, Terminology | No Comments »

Medical Transcription and Life Insight

Thursday, June 24th, 2010

Summer is coming, well, somewhere it is! Here in Western Washington that is questionable. Nonetheless, this is a good time to remind ourselves to take care of our skin so we don’t end up as a chart note in the dermatologist’s office.

Oftentimes medical transcriptionists will type the ABCD’s of melanoma, but what do they really mean? To begin with, a melanoma is a tumor of pigmented skin cells. The ABCD meanings are as follows: A is for assymmetry; one half is unlike the other half. B refers to the border; irregular border. C signifies the color; the melanoma varies in color within itself. Lastly, D relates to the diameter, which is usually larger than 6 mm.

About 60,000 new cases of melanoma are diagnosed just in the US alone each year. So, slather on that sunscreen and remain the MT, not the patient!

Posted in Healthy Living, Terminology | 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.

 

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

The Future of Medical Transcription

Tuesday, June 15th, 2010

Even if you haven’t been in the medical transcription field for long, undoubtedly you have heard about the dreaded voice/speech recognition software that is  going to put all the MTs out of business, according to rumors.

This very same subject has been making the rounds for years. True, it does exist, true it is being used, but not 100% effectively.

Healthcare provider dictation is an ever-growing industry. Unfortunately, qualified MTs are not growing at that same rate, though we are doing our best! The voice recognition technology (VRT) is picking up some of the slack but it has quite a few limitations. Experienced MTs are still very much needed to correct machine-generated errors with their knowledge of the medical language and the medical record itself.

For the qualified and experienced medical transcriptionist, there are no employment worries. 

Posted in Employment Questions, Internship Questions, Med Workshops Forum FAQ, Newbie FAQ | No Comments »

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.

Posted in Editing and Proofreading, Grammar and Style, Newbie Medical Transcriptionists, Transcription Tips | No Comments »

Medical Transcription Word of the Week

Thursday, June 10th, 2010

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.

Posted in Anatomy and Physiology, Newbie Medical Transcriptionists, Terminology | No Comments »

Medical Transcription Tips

Tuesday, June 1st, 2010

Affect versus effect. How do you know when to use which one?

Amazingly enough it is pretty clear. Most of the time you use affect as a verb and effect as a noun. Knowing the definition of each is helpful as well. Affect means to effect a change, to influence. Effect means a result.

Examples would be: “The price of fuel will affect how people travel this summer” and “We are still feeling the effects of the oil crisis at the gas pump”.

There is an exception to this “rule” but we will broach that subject at a later date.

Hopefully this article was effective in increasing your knowledge and affected you in a positive manner!

Posted in Uncategorized | No Comments »

Medical Transcription Terms

Tuesday, June 1st, 2010

Labyrinth. A maze? A part of the ear? An ’80s sci-fi David Bowie flick? All of the above but today we will just talk about the ear.

The ear is an amazing thing. Not only is it needed for hearing but for balance as well. It consists of three parts-the outer ear, the middle ear, and the inner ear. The inner ear is where you will find bony tubes with fluid and those tubes contain cell membrane lined tubes. These bony tubes are called the bony labyrinth. 

The bony labyrinth has three sections as well-the cochlea, which is responsible for your hearing; the semicircular canals, which are associated with balance; and the vestibule, which connects the two.

A very complicated thing, the ear, and this is only a part of it. Much more interesting than the movie, but that is just MY opinion of course! Word of the week, labyrinth.

Posted in Anatomy and Physiology, Newbie Medical Transcriptionists, Terminology | No Comments »