Essentials of M edical T ranscription

1. Essentials ofMedicalTranscription Presented by ARLENE N. BARATANG

2. Chapter 1 What is Medical Transcription?

3. Medical Transcriptionist • Medical transcriptionist transcribe dictated medical information that describes the condition, care, and treatment of a patient.

4. Personal Attributes, Skills, and Knowledge 1 • Organized • Work independently with little or no supervision • Interested in medical language • Disciplined to work within time constraints • Inquisitive

5. Personal Attributes, Skills, and Knowledge 2 • Can enjoy learning new concepts • Can concentrate for long periods of time • Posses common sense and sound judgment • Enjoy detail and precision • Discreet in handling confidential information

6. Skills needed for Transcriptionists • Computer and word processing skills • Fast and accurate keyboarding skills • Proofreading skills • Critical thinking skills • Hearing acuity

7. Careers for Transcriptionists • Hospitals • Doctors’ Offices • Insurance Companies • Clinics • Government medical facilities, and • Medical Transcription Services

8. Careers for Experienced MT • Supervisor or manager • Quality assurance expert • Instructor • Author • Editor • Consultant • Business Entrepreneur

9. Medical Transcription Documents • Office chart notes • History & physical examination • Consultations • Letters • Memos • Admission notes • Operative reports

10. Medical Transcription Documents • Discharge summaries • Laboratory & diagnostic tests

11. Medical Transcription Documents • These documents comprise the patient’s medical records, which becomes the communication medium for patient’s treatment and care, insurance and reimbursement, legal documentation, and research support.

12. Medical Transcription Models *A model job description developed by the American Association of Medical Transcription (AAMT).

13. Sample Chart Note Using SOAP Note Style CHART NOTE Patient Name: Felter, Michael Date of Birth: July 3, 1954 Examination Date: current date SUBJECTIVE: Patient complains of right elbow pain for past three months. He has been playing tennis once a week over the summer with gradually worsening pain.

14. Sample Chart Note Using SOAP Note Style OBJECTIVE: Tenderness over right medical epicondyle. Pain radiates to the forearm and back on the hand with flexion and supination. Assessment: Epicondilitis PLAN: Advised patient to stop playing tennis for three weeks and rest elbow until inflammation subsides. Prescribed Mortrin 200 mg p.o. q.i.d. Urged the patient to wear an elastic strap for support, when playing tennis in the future.

15. Sample Chart Note Using SOAP Note Style PLAN: Advised patient to stop playing tennis for three weeks and rest elbow until inflammation subsides. Prescribed Mortrin 200 mg p.o. q.i.d. Urged the patient to wear an elastic strap for support, when playing tennis in the future. Harry A. Medulla, MD Harry A. Medulla, MD/xx

16. Sample X-Ray Report X-RAY REPORT Patient Name: Farley, Cassandra File Number: 5690341 Date of Birth: February 1, 19xx Examination Date: current date Ordering Physician: Izzy Sertolli, MD Examination: PA AND LATERAL CHEST X-RAY

17. Sample X-Ray Report HISTORY: This is a 57-year old female with a history of lung cancer and increased shortness of breath for one week. FINDINGS CHEST: There is mid fibrotic change at both lung bases, over the left lung apex, and along the left chest wall laterally. There is some deformity to the left rib cage, apparently reflecting several old, healed rib fractures. There are some increased markings at the left lung base.

18. Sample X-Ray Report IMPRESSION: Early pneumonia, superimposed upon the underlying fibrotic changes. The heart size is normal. Adam Valence, MDAdam Valence, MD/xx * Medical reports typically used in outpatient facilities.

19. Assignment: • Bring the following sample reports from any hospital or doctors’ clinic records: • Chart note using history and physical style • History and Physical Examination • Consultation report (Informal style with headings) • Diagnostic Imaging letter • Consultation Letter (Formal style without headings)