Medical Transcription

6 Pages·00.731 MB·English

by  BarCharts, Inc.

BarCharts, Inc.® WORLD’S #1 ACADEMIC OUTLINE
Essentials of Procedures, Terminology, Editing, Reports, Anatomy & Physiology, Concepts of Disease, Medical & Surgical Procedures & More

overview record or the patient’s entire chart, which will contain all reports from previous
Scope of Practice encounters
• It is very important to have a properly formatted, thoroughly edited, and care-
• The medical transcriptionist (MT) is an allied health professional who deals fully reviewed medical transcription document—if the MT accidentally types a
with the process of converting voice-recorded reports from physicians and/or wrong medication or the wrong diagnosis, the patient can be at risk if the
other healthcare professionals into written or text format doctor does not review the document for accuracy
• The MT is a medical language specialist who is aware of the: • Both the doctor and the MT play an important role in making sure that the
w standards and requirements that apply to the patient’s health record transcribed dictation is correct and accurate
w legal significance of medical transcripts • The doctor should speak slowly and clearly, especially when dictating medi-
• The MT is the primary route of communication between the physician and cations or details of diseases and conditions, and the MT must possess:
other healthcare providers who access patient medical records w hearing acuity
• Many types of patient care documents exist, including: w medical knowledge
w histories and physical examinations w good reading comprehension
w progress reports w fact-checking skills (in order to check references when in doubt about the
w emergency room notes dictation)
w consultations • The MT is bound to transcribe verbatim (exactly what is said) and make no
w operative reports changes, but has the option to flag any report inconsistencies
w discharge summaries w on some occasions, doctors do not speak clearly, or voice files are garbled
w clinic notes
• Some doctors are, unfortunately, time-challenged and need to dictate their
w referral letters
reports quickly (as in ER reports)
w radiology reports
w in addition, there are many regional and/or national accents and mispronun-
w pathology reports
ciations of words with which the MT must contend
w an array of documentation spanning more than 60 medical specialties and
• It is imperative that the MT look up the correct spelling of complex medical
subspecialties
terms, medications, obvious dosage or dictation errors—this is a large part of
• MTs often work for hospitals, clinics, physician offices, national transcription
the job of the MT, and, when in doubt, he/she should “flag” a report
services or other medical offices
w a “flag” on a report requires the dictator to fill in a blank on a finished report,
• The practice of medical transcription is changing rapidly; advances in technol-
which has been returned to him/her, before it is considered complete
ogy require a professional who is comfortable with the more technical aspects
• MTs are never, ever permitted to guess, or “just put anything” in a report
of documentation in an ever-changing electronic environment
transcription!
Medical Transcription Process • Furthermore, medicine is constantly changing—new equipment, new medical
• When the patient visits a doctor, the doctor spends time with the patient dis- devices and new medications enter the market on a daily basis, and the MT
cussing his/her medical problems, including past history and/or problems needs to be a critical thinker and to research and find the meanings of these
• The doctor performs a physical examination and may request various new words
laboratory tests and/or diagnostic studies, as well as prescribing medi- w MTs need to have access to, or keep on hand, an up-to-date library to quickly
cation and possibly recommending a surgical procedure facilitate the correctly spelled insertion of every device, procedure and/or
• The doctor makes a diagnosis and decides on a plan of treatment for the medication dictated
patient, which he/she then discusses with and explains to the patient Association for Healthcare Documentation Integrity (AHDI)
• After the patient leaves the office, the doctor uses a voice-recording device to • The Association for Healthcare Documentation Integrity (AHDI) is of crucial
record the information about the patient encounter
importance to the MT
• This information may be recorded into a hand-held cassette recorder or into a • The AHDI curriculum is followed by many schools in the United States that
regular telephone that dials into a central server located in the hospital or tran-
offer medical transcription as a course
scription service office; either way, the report is “held” for the transcriptionist • Key documents produced by the AHDI are:
• The MT then accesses this report, which is received as a voice file or cassette
w Medical Transcriptionist Bill of Rights
recording
w AHDI Code of Ethics
• The MT then listens to the dictation and transcribes it into the required format
• To read these documents in their entirety and/or to learn more about AHDI,
for the medical record
visit their Web site: www.ahdionline.org
• This medical record is considered a legal document
• The next time the patient visits the doctor, the doctor will call for the medical
skills, knowledge & procedures keyboard kinetics & computer literacy
• Medical transcriptionists (MTs) are more than just data-entry operators or mere • Typing speed is important in the productivity of a transcriptionist
typists working in the healthcare industry w techniques for building speed and efficiency on the keyboard are invaluable
• MTs need to have the skills required for creating proficient and accurate medi- tools for improving typing speed
cal records; besides having these skills, they need to constantly improvise and w usually, the industry requirement is 60–80 words per minute (wpm)
hone their skill-sets • The MT must also possess strong computer skills, with general knowledge of
• MTs are expected to be proficient in English language use and grammar, and ability to operate designated dictation and transcription equipment
medical terminology, anatomy and physiology, disease processes, and medical • The MT must be able to use basic features of word processing programs:
record-keeping, as well as having advanced proofreading and editing skills, w inserting and deleting text
versatility in the use of transcription equipment and computers, and the highly w creating macros
developed analytical skills and deductive reasoning necessary to convert dic- w saving changes/features
tated sounds into meaningful form • The MT must be able to identify and secure confidentiality
• These skill-sets are described in detail in the sections that follow, but can be issues and use:
summarized as: w password protection
1. Keyboard Kinetics & Computer Literacy w antivirus software
2. English Language Proficiency – Grammar, Sentence Structure, w encryption
Spelling, Punctuation, Numbers & Abbreviations • The MT must be able to:
3. Medical Terminology w differentiate between stand-alone and networked
computers
4. Editing & Proofreading Medical Dictation
w understand the basic concepts of dictation and
& Transcription
transcription technology
5. Medical Reports The MT Knows • MTs have many types of equipment and refer-
6. Human Anatomy & Physiology ence materials at their fingertips; basic equip-
Logic and critical thinking are
7. Concepts of Disease ment available includes:
key to accurate transcription
8. Medical & Surgical Procedures w transcriber*
documents and, thereby, key
9. P&h Laarmboarcaotloorgy yM, Deidaigcinnoestic Imaging to effective patient care ww ccourmrepnutt werord-processing software
w printer
10. Medicolegal Issues
1
Keyboard Kinetics (continued)
w headset The MT Knows Punctuation
w foot pedal Typing speed and accuracy are a The correct use of punctuation is crucial for the MT
w sound card must for the effective MT, but so because most dictators of medical records do not bother to
[* N OTE: Transcribers can be as simple as audiocassette are knowledge of and comfort in include punctuation
players or as evolved as computerized voice processing using cutting-edge technology
machines, voice synthesizers and remote digital dictation] Key Punctuation Marks
• MTs must be able to use basic transcription equipment—both analog and digital—as well as all apostrophe ’
the equipment in the above list asterisk *
• MTs must be aware of copyright law implications and basic concepts of electronic healthcare backward slash \
records
braces/curly brackets { }
brackets [ ]
English language proficiency
colon :
• The MT must know and be able to apply the rules of the English language! comma ,
• These rules include proper use of grammar, sentence structure and punctuation, as well as correct ellipsis points . . . (note three dots only, unless preceded
spelling (including knowledge of synonyms, antonyms, homonyms, acronyms and commonly used/ by a period if used at the end of a sentence)
misused, misspelled and confused words, particularly within medical terminology) and accurate
em-dash —
representation of numbers, abbreviations, etc.
en-dash –
Grammar
exclamation point !
The MT must know the definitions of and the differences among all elements of grammar
• Nouns: words that refer to persons, places, things, ideas or qualities forward slash/virgule /
w nouns are the most commonly used part of speech, and sentences may contain more than hyphen -
one noun parentheses ( )
w nouns are further classified as proper, common, concrete, abstract, collective and verbal period .
w MTs must know when to capitalize nouns used in medical dictation
question mark ?
• Pronouns: words that substitute for nouns and function like nouns in sentences
quotation marks “_”
w classified as personal, demonstrative, relative, interrogative, reflexive, intensive and indefinite
w nouns and pronouns can be subjects (doer of the action of the sentence) or objects (action of semicolon ;
the sentence is done to them) single quotation marks ‘_’
EX: I gave money. (I is the subject) EX: Money was given to me. (me is the object) (used for quotation within another quotation)
• Verbs: words that express actions, happenings or states of being
w predicates: groups of words containing verbs and words that describe or modify verbs Numbers & Abbreviations
• Adjectives: words that describe or modify nouns and/or pronouns
The MT understands correct use of
• Adverbs: words that describe or modify verbs, adjectives and/or other adverbs Arabic Roman
both Arabic and Roman numerals
• Articles: determiners that indicate a noun will follow Numerals Numerals
• The MT understands correct use
w definite article is the 1 I
of units of measure and is able
w indefinite article is a or an to identify their abbreviations 5 V
• Conjunctions: words that join one part of a sentence to another
• However, using abbreviations 10 X
• Prepositions: words that describe the relationship of one thing to another
can be an asset or a liability to 50 L
w prepositions should come before objects the MT—sometimes abbrevia-
w prepositions should not come at the end of sentences tions are used as time savers by 100 C
Sentence Structure the dictator; other times abbre- 500 D
• Every sentence has a subject and a predicate; depending upon how complex the sentence is, viations are not well known, or 1,000 M
it may be made up of multiple clauses and/or phrases are unclear, ambiguous or inap-
• Sentences are made up of clauses and phrases propriate for use in medical transcription
• Clauses: groups of related words containing a subject and a predicate that is not a complete sentence
w clauses are often set off from other parts of a sentence or other clauses by prepositions, conjunc- Metric Metric Unit
tions and clause introducers Abbreviation of Measure
• Phrases: groups of related words lacking either a subject or a predicate ng, nL, nm nanogram, nanoliter, nanometer
w phrases are not complete sentences by themselves, but they often stand alone
w phrases often appear alone when used in categories such as: mcg, mcL, mcm microgram, microliter, micrometer
- review of systems mg, mL, mm milligram, milliliter, millimeter
- physical examination The MT Knows
cg, cL, cm centigram, centiliter, centimeter
- laboratory data Knowledge of grammar, punctuation, spelling,
dg, dL, dm decigram, deciliter, decimeter
Spelling acronyms, numbers and abbreviations enables
The MT must be able to apply the rules of spelling, the MT to correctly transcribe incorrect sentences; g, L, m gram, liter, meter
and know how to spell commonly used, misused, it is essential for the MT to know the difference Dg, DL, Dm dekagram, dekaliter, dekameter
misspelled and confused words between jargon, slang, street talk and profanity,
hg, hL, hm hectogram, hectoliter, hectometer
Spelling Hints and be able to transcribe accurately
kg, kL, km kilogram, kiloliter, kilometer
• Do not rely exclusively on pronunciation
• Do remember that there can be different forms of the same word
• Do use preferred American spellings
• Do know the difference between words with “ie” and “ei” spellings • Correct misspelled and misused words
EX: quiescent • seizure • vein • Recognize homonyms, synonyms, antonyms and acronyms
• Do know when to keep or drop the final “e”: w homonyms: words that sound or are pronounced alike, but are differ-
w drop the “e” before adding “-able”, “-ible” or “-ing” if the ending begins with a vowel ent in meaning
• Do know when to keep or drop the final “y” EX: a ural (pertaining to ears) vs. oral (pertaining to mouth)
coarse (thick) vs. course (a path or regimen)
w change the “y” to “i” when it follows a consonant and when adding an ending
ileum (intestine) vs. ilium (hip bone)
EX: hurry‡hurries apply‡applied
w synonyms: words that have the same meaning
• Do double consonants when adding an ending with single syllable words
EX: disease = illness = sickness = ailment = malady
EX: stop‡stopping tan‡tanned w antonyms: words that have opposite meanings
w exceptions to this rule on doubling consonants: EX: abduct vs. adduct
- in most cases DO NOT double the consonant when two vowels or a vowel and hypertension vs. hypotension
another consonant precede the final consonant macroscopic vs. microscopic
EX: start‡starting jump‡jumped principal vs. secondary
w double the final consonant when a single vowel precedes the final consonant and the w acronyms: words comprised of the first letters in a series of words
stress falls on the last syllable of a word with two or more syllables or in a phrase; sometimes acronyms are pronounced as words, but
EX: refer‡referral begin‡beginning not always
w DO NOT double the final consonant when two vowels or a vowel and another conso- EX: AIDS (Acquired Immune Deficiency Syndrome)
nant precede the final consonant, or when the stress falls on a syllable other than the CABG (coronary artery bypass graft)
last syllable in a word with two (or more) syllables HEENT (head, ears, eyes, nose, throat)
EX: referral‡reference committed‡commitment REM (rapid eye movement)
• Recognize commonly used words, misused words and misspelled words; if you can SIDS (Sudden Infant Death Syndrome)
spell a word, you can look it up to find out its meaning, if in doubt [Note that syndrome names are capitalized]
2
medical terminology
w combining form: root combined with a slash(/) and the letter “o”
• The MT must be able to divide, analyze and define complex medical words • The MT must also be able to build basic medical words by using prefixes,
by recognizing their prefixes, suffixes, root words and combining forms suffixes, root words and combining forms
w prefix: beginning portion of word • In addition, the MT must know how to correctly spell, use and pronounce
w suffix: ending portion of word medical terms
w root: basic component of word; the root is the simplest element of a word • The ability to apply proper word endings for plurals, including endings of
from which its meaning can be derived Greek and Latin origin, is also a must
Common Medical Terminology Prefixes Common Medical Terminology Suffixes
a- not or without inter- between -algia pain -oma tumor
ab- away from intra- within -cele tumor, swelling or hernia -osis syndrome
-cision surgical cutting -partum birth
ad- to or toward mal- bad or abnormal
-cyte type of cell -pathy disease process
ante- before neo- young or new
-ectomy surgical removal -philia affinity for
anti- against para- beside or beyond
-emia condition of the blood -phobia fear of or aversion to
bi- two peri- around -gram write or record -plasm form or formation
brady- slow post- after -graphy write or record -plasty surgical repair
con- with or together pre- prior -ia condition -plegia paralytic condition
dys- opposite pro- earlier than -iac one who suffers from -pnea breathing condition
a condition
ecto- outside re- back or again
-iasis state or condition of -rrhea flowing
endo- inside retro- backward
-ic pertaining to -scopy observatory procedure
epi- upon, after or in addition sub- under or below -itis inflammatory condition -stomy orifice
extra- outside of or beyond sym-/syn- with or together -lith stone formation -thesis act of putting/placing
hyper- above, beyond or extreme tachy- fast or quickened -logy study of -tomy surgical cutting or incision
-lysis breaking down or -trophy growth of nerves
hypo- under, below or ultra- beyond
decomposition
less than normal or excessively
-metry measurement of -uria urinary condition
in- not uni- one
-mortem death
Commonly Misspelled Medical Terms
The MT Knows
Understanding the accommodation auricle curette extraocular maneuver piriform sinus
language of medi- aggravated auricular defervescence fascicular mucus pseudomonas
cine is the most alveolar auscultation dependent fluorescent ophthalmic pterygium
important and vital
annulus breathe diarrhea hemoptysis ophthalmology purulent
aspect of a career
antihelix bruit diuresis hemorrhage palpitation rhabdomyosarcoma
as a transcription-
ist; improving one’s aphthous buccal duodenum hyoid parenchyma rhinitis
medical vocabulary apneic caudal ecchymosis in situ paresis sphenoid
is a must for a suc- apparent choana emphysema inguinal phalangeal telangiectasia
cessful MT! appendiceal cholesteatoma eschar intermittent phalanges tenacious
ascites commissure esophageal laryngeal pharyngeal tic
asymmetrical compatible esophagus lysis phlegm tinnitus
asymptomatic condyle exquisite malar phonate vesicular
[NOTE: There are too many common roots and combining forms to list here, but some commonly misspelled medical terms are included; for more detailed lists of medical terms (roots,
combining forms, prefixes and suffixes), see QuickStudy guides on Medical Terminology: The Basics and Medical Terminology: The Body]
editing & proofreading medical dictation & transcription
Three Steps of Editing w DO NOT edit dictation if the editorial changes would alter the dictator’s
1. Content editing: editing the copy for errors in style, grammar, sentence meaning; instead, flag it
structure, spelling and punctuation Proofreading The MT Knows
2. Copyediting: editing the copy for typographical errors made by the transcrip- • Proofreading involves reading the docu- The successful MT must have
tionist ment word for word before the final print- advanced editing/proofread-
3. Spell checking: checking the document both manually (i.e., reading it over ing or typesetting ing skills; not only must he/
and looking up spellings you are unsure of) and electronically (i.e., using the
• Copyediting and content editing often are she know when editing and/
computer spell checker)
grouped together as part of the proofread- or proofreading are necessary,
• There are specific instances when the MT should NOT edit the dictation being
ing process, but, ideally, both should be but also how to properly edit
transcribed:
done prior to proofreading and are NEVER and proofread so as not to
w DO NOT edit dictation when there is an unclear inconsistency, or when you
a substitute for proofreading! change the meaning or con-
are not reasonably sure about how to make a correction
• Spell checking is NEVER a substitute text of the original dictation
w DO NOT edit dictation if you are unaware of or confused about the dicta-
for proofreading!
tor’s meaning
medical reports • The physical component of this report is composed of the visual evaluation,
what is heard, what is felt and what is smelled (sensed by the nose)
• Each medical report has a unique format specifically tailored to make it con- • This is the hands-on evaluation performed by the physician or healthcare provider
cise, clear and uniform
• Most medical reports are broken down into various sections, and those sec- Consultation Report
tions are further broken down into subsections • A report from the specialist physician to the patient’s primary physician, the consul-
• The sections have titles called headings and the subsections have titles called tation is like a second opinion regarding a particular problem or diagnosis
subheadings • The consultation report contains an evaluation of the patient’s condi-
• Dictators usually follow these headings and subheadings as guides for tion from the standpoint of the specialist, an impression of the patient’s
covering each aspect of the medical report condition, and recommendations on how to treat the patient
• This report also contains (if appropriate):
Six Basic Hospital Reports
w date of consult
History and Physical (H & P) w pathology reports
• The history component of this report covers the summary of the chronological w surgical reports
situation, events and other associated topics that may have contributed to the w imaging reports
patient’s condition w laboratory results
3
• There is usually a complimentary close at the end of the report such as • The pathology report is dictated by the pathologist, who reports on the:
“thank you for the referral” w gross (i.e., visible) findings
Discharge Summary w microscopic findings
• Summarizes the patient’s in-hospital stay • This report concludes with a pathological diagnosis
• The discharge summary details: Radiology Report/Imaging Report
w the reason the patient was admitted • These are reports that describe diagnostic procedures done in the
w the patient’s medical history radiology department and are dictated by a radiologist
w a review of the events that occurred while the patient was hospitalized • Some of the exams performed in radiology involve the use of:
• Usually, the physician will dictate: w computerized tomography (CT) scans
w follow-up instructions The MT Knows w fluoroscopy
w discharge medications The MT must not only w interventional radiography
w the patient’s condition when discharged know which tools to w magnetic resonance imaging (MRI)
w the patient’s prognosis use when transcribing, w mammography
Operative Report but he/she must also w nuclear medicine (nuc med)
• Describes an operation or surgical procedure be familiar with the w positron emitting tomography (PET)
• The operative report contains: proper order and orga- w single photon emission computed tomography (SPECT)
w a description of the surgical procedure nization of the informa- w ultrasound/sonography
w the name of the surgeon tion being transcribed w x-ray
w the title and date of the surgery and how it should be • The radiology report contains:
w the indications for surgery placed (formatted) w the diagnostic examination
w the surgical findings w a description of the examination
w the sponge count w the findings
w the amount of blood lost during the procedure w the diagnostic impression
• The operative report ends when the patient is taken to recovery and will • A diagnostic report will also contain:
state the condition of the patient w the amount of radioactive material given to the patient
Pathology Report w the amount of barium used for a fluoroscopic procedure
• Describes the pathological (i.e., disease-related) findings of tissue w the amount of contrast material used in an IV injection for a CT scan
samples taken during surgery, biopsy, special procedure or autopsy w the amount of gadolinium injected for an MRI procedure
human anatomy & physiology • Reproductive system: sex organs
w key components (female): ovaries, fallopian tubes, uterus and vagina
The MT must be able to understand human anatomy (structures) and
physiology (functions and activities) w key components (male): testes, vas deferens, seminal vesicles, pros-
tate and penis
Basic Biology
• Respiratory system: organs used for breathing
The MT must understand and be able w key components: nose/nasal passages, pharynx, larynx, trachea,
to define essential biological terms cell – tissue – organ – system
bronchi, lungs and diaphragm
• Cell: structural and functional unit • Skeletal system: structural support and protection
of all known living organisms; often called the building block of life w key components: bones, cartilage, ligaments and tendons
• Tissue: cellular organizational level intermediate between cells and a • Urinary system: maintains fluid balance, electrolyte balance and elimina-
complete organism; ensemble of cells that carry out a specific function; tion of liquid waste (excreted urine)
tissue cells are not necessarily identical, but they are of the same origin
w key components: kidneys, ureters, bladder and urethra
• Organ: tissue that performs a specific function or group of functions
• System: group of organs that work together to perform a certain task Basic Body Positions, Directions & Planes
Basic Anatomy The MT must be able to locate and identify terms describing anatomi-
cal positions and directions
The MT must be able to name the major body systems and their
components, while also being able to describe their locations and
anterior nearer to the front of the body
meanings, and knowing which organs are part of multiple systems
posterior nearer to the back of the body
(EX: pancreas is part of both the digestive and endocrine systems)
• Circulatory system: pumps and channels blood to and from the body dorsal posterior (back side) of the body
and lungs ventral anterior (front side) of the body
w key components: heart, blood and blood vessels lateral farther from the midline of the body
• Digestive system: processing food; digestion, absorption and elimina-
medial nearer to the midline of the body
tion (solid waste)
w key components: salivary glands, esophagus, stomach, liver, gallblad- proximal nearer to the point of origin
der, pancreas, intestines (small and large), rectum and anus distal farther from the point of origin
• Endocrine system: communication within the inferior away from the head
body using hormones made by glands
superior toward the head
w key components (glands): hypothalamus,
pituitary, pineal, thyroid, parathyroids caudal inferior in position
and adrenals; certain glands also func- cranial superior in position
tion within other systems (EX: pancreas –
digestive; ovaries and testes – reproductive)
• Integumentary system: first defense against The MT must also be able to identify the planes of the body
foreign matter and controls temperature • Coronal (a.k.a., frontal) plane: divides the body into anterior and
w key components: skin, hair and nails posterior sections
• Lymphatic & immune system: structures (nodes
• Sagittal (a.k.a., midsagittal or median sagittal) plane: divides
and vessels) involved in the transfer of lymph
the body into left and right
between tissues and the bloodstream; de-
fends against disease-causing agents • Transverse (a.k.a., horizontal) plane: divides the body
w key components: leukocytes (white blood into inferior and superior sections
cells), tonsils, adenoids, thymus and Basic Body Cavities, Organs & Regions
spleen
The MT must be able to identify body cavities
• Muscular system: movement of the body, and
and the organs contained in those cavities
other involuntary functions (including contrac-
tions of the heart, which is a muscle) • Abdominopelvic cavity: lower portion of the
w key components: muscles (600+, including: ventral body cavity, it is often divided into
skeletal, involuntary, cardiac) the superior abdominal and inferior pelvic
• Nervous system: collecting, transferring and cavities
w abdominal cavity: space that con-
processing information
tains the digestive organs and glands
w key components: brain, spinal cord, periph-
(i.e., liver, gallbladder, spleen, kidneys,
eral nerves, autonomic nerves and sense
pancreas, stomach, small intestine and
organs
the majority of the large intestine)
4
Human Anatomy & Physiology (continued)
Basic Body Cavities, Organs & Regions (continued) w mediastinum: contains the trachea, esophagus, thymus and heart, as
w pelvic cavity: space surrounded by the pelvis and containing the infe- well as the vessels connected to the heart and the pericardial cavity,
rior portion of the large intestine, bladder, uterine tubes (females) and which is the area surrounding the heart
reproductive organs • Ventral body cavity: contains the organs in the chest and abdomen; it is
• Cranial cavity: fluid-filled space inside the cranium (skull) that contains further divided by the diaphragm into the superior thoracic cavity and the
the brain inferior abdominopelvic cavity
• Dorsal body cavity: space within the cranium (skull) and the spinal canal, The MT must be able to locate and identify the anatomical and clinical
which is surrounded by the vertebrae divisions of the abdomen
• Spinal cavity: space that encloses the spinal cord and extends from the
cranial cavity to the base of the spine
• Thoracic cavity: upper portion of the ventral body cavity, it contains the
lungs, heart, lower esophagus, thymus gland, and other organs of the
Epigastric
cardiovascular, respiratory and lymphatic systems
Right Left
w subdivided into: right pleural cavity of the right lung, the left pleu-
Hypochondriac Hypochondriac
ral cavity of the left lung and the mediastinum, which is between the Epigastric
Umbilical
pleural cavities
Hypogastric
Right Lumbar Umbilical Left Lumbar
The MT Knows
A general understanding of the
human body and how it works right left
is essential to the successful upper upper
MT, including basic knowledge Right Inguinal Left Inguinal
of all major body systems— right left Hypogastric
circulatory, digestive, endocrine, lower lower
integumentary, lymphatic & im-
mune, muscular, nervous, repro- 4 Quadrants of the Abdomen 9 Regions of the Abdomen
ductive, respiratory, skeletal & right upper quadrant RUQ
urinary—their functions, organs right hypochondriac epigastric left hypochondriac
right lower quadrant RLQ
and common diseases right lumbar umbilical left lumbar
left upper quadrant LUQ
left lower quadrant LLQ right inguinal hypogastric left inguinal
concepts of disease
one who has it, with a bodily discharge of such a patient, with an object
touched by such a patient or by bodily discharges
The MT must possess a basic understanding of disease and the causes
• Hemodynamic disorder: blood or bleeding problems
of disease
• Immunopathology: a branch of medicine that deals with immune
• Identify major pathological conditions and disease processes that affect
responses associated with disease; includes the study of the pathology
each body system
of an organism, organ system or disease, with respect to the immune
• Understand and know the direct causes of diseases
system, immunity and immune responses
• Recognize the general morphology of organisms and their role in the
• Infectious disease: a clinically evident disease resulting from the pres-
disease process
ence of pathogenic microbial agents
• Know the signs and symptoms of the diseases of each body system
• Inflammation: biological response of vascular tissues to harmful stimuli,
• Be able to describe the diagnostic procedures for the diseases of each such as pathogens, damaged cells or irritants
body system
• Injury: damage or harm caused to the structure or function of the body
• Know the prognosis and prevention of the diseases of each body system caused by an outside agent or force
• Have knowledge of blood-borne diseases and their transmission • Nature of disease: an abnormal condition of an organism that impairs
• Be able to practice infection control and follow universal precautions bodily functions, associated with specific symptoms and signs
The MT must be able to define and describe terminology associated • Repair: process by which the body begins to heal itself
with disease
• Cancer: a class of diseases in which a group of cells displays uncontrolled
The MT Knows
growth, invasion and sometimes metastasis (spreading to another part of
The MT must have a fundamental understanding of the
the body)
nature of diseases, their treatments, etiology, signs and
• Communicable disease: an infectious disease transmissible (as from
symptoms, as well as diagnostic and treatment modali-
person to person) by direct contact with an affected individual or that
ties, prognoses, prevention, and pathologies of selected
individual’s discharges or by indirect means (as by a vector)
human systems
• Contagious disease: an infectious disease communicable by contact with
medical & surgical procedures The MT must be familiar with different anesthesia types
The MT must be familiar with different types of surgical instruments Local Anesthetics General Anesthetics
• Carriers and appliers for optical, electronic and mechanical devices Amethocaine Desflurane
• Clamps and occluders for blood vessels and other organs Bupivacaine Enflurane
• Dilators and specula for access to narrow passages or incisions Cocaine Halothane
• Distractors, positioners and stereotactic devices Dibucaine Isoflurane
• Graspers, such as forceps
Levobupivacaine Nitrous Oxide
• Irrigation and injection needles, tips and tubes, for introducing fluid
Lidocaine Sevoflurane
• Measurement devices, such as rulers and calipers
Mepivacaine
• Mechanical cutters (scalpels, lancets, drill bits, rasps, trocars, etc.)
Prilocaine
• Powered devices, such as drills and dermatomes
Procaine
• Retractors, used to spread open skin, ribs and other tissue
Ropivacaine
• Scopes and probes, including fiber-optic endoscopes
The MT Knows
and tactile probes
Medical and surgical reports are generated every day, and the MT needs to
• Suction tips and tubes, for removal of bodily fluid
have knowledge of surgical specialties, pathology reports, types of drugs
• Tyndallers, to help “wedge” open damaged tissue in the brain
and anesthesia used in the operating room (OR), the anatomy (structure)
• Ultrasound tissue disruptors, cryotomes and cutting laser guides being operated on and the types of surgical instruments used
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pharmacology, diagnostic imaging & laboratory medicine • The MT must be able to identify normal laboratory value ranges
w laboratory values are dependent upon the lab doing the testing, but the
Knowledge of the basics of pharmacology, diagnostic imaging and laboratory
MT should have some knowledge of:
tests are essential to effective medical transcription
- blood values
• The MT must be able to identify common diagnostic imaging modality
- cancer tumor markers
testing, such as:
- cardiac enzymes
w computed tomography (CT) scan
- hormones
w echocardiogram - lipids
w fluoroscopic procedures - urinalysis
w interventional radiography - and other values for common tests that doctors may order
w magnetic resonance imaging (MRI) • The MT must also be able to identify, pronounce, spell, define and ap-
w mammography ply drug categories
w nuclear medicine w analgesics: relieve pain
w positron emission tomography (PET) scan w anesthetics: suppress the sensation of feeling
w radiography (a.k.a., diagnostic radiology [DR]) w antianxiety drugs: calm anxious feelings and relieve muscle spasms
The MT Knows
w single photon emission computed w antibiotics: suppress growth of bacteria
tomography (SPECT) scan Understanding the language w anticoagulants: prevent blood from clotting
w ultrasound (a.k.a., sonography or used in pharmacology, diag- w anticonvulsants: inhibit or control seizures
ultrasonography) nostic imaging and labora- w antidepressants: affect communication between cells
• The MT must be able to differentiate among tory medicine—including: w antidiarrheals: control gastrointestinal distress
common tests used in pathology and labora- drug classes, dosages and w antiemetics: prevent and control nausea and vomiting
tory medicine, including: routes of administration; di-
w antifungals: treat fungal infections
w diagnostic indications agnostic imaging modalities;
w antihistamines: block histamines; used to treat allergies
w techniques laboratory diagnostic tests,
w antihypertensives: lower blood pressure
w expression of values indications, techniques, ex-
w anti-inflammatories: reduce inflammation
w significance of findings pressions of values and sig-
w antineoplastics: chemotherapeutic agents
• The MT must be able to identify laboratory nificance of the findings—is
w antivirals: treat viral infections
testing methods for various diseases and critical to accurate medical
w corticosteroids: reduce inflammation
conditions: transcription
w diuretics: remove fluid from cells
Amino Acids Lipid Panel w narcotics: federally controlled substances that relax the central nervous
system and relieve pain
Chem 7 Liver Function Panel w tranquilizers: relieve anxiety
Coagulation PSA • Furthermore, the MT must be able to distinguish common drug classes,
forms and dosages and know the routes of drug administration:
Complete Blood Count (CBC)* Renal Function Panel
w oral
Coronary Thyroid w rectal
Electrolyte Panel Toxins w mucous* membrane [*mucous is correctly spelled here because it is used as an
w topical adjecti ve, modifying membrane; BUT, mucus is the correct
Glucose Panel Tumor Markers w parenteral spelling for the noun form: mucus is a slippery secretion]
Hormone Levels Urinalysis - intradermal
- subcutaneous
Immunology Vitamins
- intramuscular
[* most commonly ordered lab test]
- intravenous (IV)
medicolegal issues
- Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
• The MT continually handles privileged patient information - National Committee of Quality Assurance (NCQA)
• When producing “official reports” it is imperative for transcriptionists to be - Health Level 7(HL7)
aware of:
- Centers for Medicaid and Medicare Services (CMS)
w current laws affecting healthcare
w patient service activities w apply the concepts of Health Insurance Portability and Accountability Act
(HIPAA)
w proper policies and procedures for completing and submitting “official docu-
w apply the code of ethics as presented by the Association for Healthcare
ments”
Documentation Integrity (AHDI)
• Therefore, the MT must:
w know that a patient’s health record is a legal document
w demonstrate a general knowledge of standards and regulations related to
healthcare documentation, as set by the following organizations: The MT Knows
- Association for Healthcare Documentation Integrity (AHDI, formerly Medical transcription requires an understand-
known as the American Association of Medical Transcriptionists [AAMT]) ing of both medical and legal concepts and
- American Health Information Management Association (AHIMA) ethics—remember that the medical record is
- American Medical Association (AMA) a legal document!
U.S. $5.95
AUTHORS: Kathryn Almquist, RT (R)(T)(CT) Customer Hotline # [phone]
Jacqueline Stawicki, RT (R)(T)(CT)
ISBN-13: 978-142321397-0
ISBN-10: 142321397-1 free downloads &
hundreds of titles at
quickstudy.com
All rights reserved. No part of this publication may be reproduced or trans- NOTE TO STUDENT: This guide is intended for informational purposes only. Due to its condensed
mitted in any form, or by any means, electronic or mechanical, including format, this guide cannot cover every aspect of the subject. This guide is not intended for the
photocopy, recording, or any information storage and retrieval system, diagnosis, treatment or cure of any medical condition or illness, and should not be used as a
without written permission from the publisher. substitute for professional medical care/advice! BarCharts, Inc., its writers, editors and designers
© 2009 BarCharts, Inc. 1009 are not responsible or liable for the use or misuse of the information contained in this guide.
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