MR250 MEDICAL TRANSCRIPTION I

Week 5Instructor:

Amber Krasny MBA, CPC, CMRS

MT Notebook…

• Please make yourself a notebook either hard copy or digital for things that you’ll want to remember.

• Once you have reviewed your dictation make note of the corrections in there for future reference.

• Put tabs in sections like punctuation/grammar, medications, abbreviations, formatting etc.

Quick Quiz…

• What is the #1 misspelled word in the English Language?

• Why do you think that is?• What can you do to

remember which one to use?

ANSWER KEY

• Its• Because it is confused with

the contraction it’s (it is).• Read the sentence by using “it

is” in it and see if that fits. If not than it is the possessive pronoun “its.”

• I had a doll it’s hair was red. Read aloud: I had a doll it is hair was red.???NO

• So it must be “its” not “it’s.”

Questions from Gilmore…Chapter 5Mechanics of Editing

Fill in the blanks…1. …improper use of __________ and ________

is not only a __________ to the reader, but it can also ______ the ________ of a ________.

2. A carelessly ________ medical _________not only makes a bad ____________, but in the case of __________reports, might _________ a patient’s _________.

ANSWER KEY

1. …improper use of punctuation and grammar is not only a distraction to the reader, but it can also change the meaning of a sentence.

2. A carelessly proofread medical document not only makes a bad impression, but in the case of medical reports, might endanger a patient’s health.

Grammar Review• Sentences are the building blocks

of writing. An independent clause can function as a complete sentence; it consists of a subject (s)and a verb (v)and expresses a complete thought.– The patient (s) left (v) the clinic.

• Most sentences contain more than a simple subject and verb.– The patient’s blood (s) work was (v)

completed, and he (s) left (v) the clinic for home.

Sentence Fragment

Sentence fragments are acceptable in medical transcription. Transcribe what is dictated—full sentence, fragment, or a list.

1. Fragments are often seen in which types of reports?

2. Give me an example from the three areas listed in your textbook.

ANSWER KEY Cont.

• They are particularly common in the physical exam, lab results, or review of systems sections of reports, even when complete sentences are used in the same sections or other parts of the report.– LUNGS: Clear.– Blood pressure: 120/80– MEDICATIONS: Coumadin 5 mg

per day, Isordil and Valium– White blood cells 17,000.

Subject Verb Agreement

Subjects must agree with their verbs in terms of number (singular or plural) and person (first, second, or third).

Why are these examples below incorrect?

1. The review of systems are negative.

2. There has been several scans showing masses in the breast.

3. Each of the nurses have a cell phone.

ANSWER KEY 1. The review of systems are

negative. The review of systems is negative. The subject is “review,” not systems. TIP: Eliminate the prepositional phrase “of systems” and see how it sounds.

2. There has been several scans showing masses in the breast. There have been several scans showing masses in the breast. The subject and verb have been reversed in this sentence, it is actually “scans”

ANSWER KEY Cont.3. Each of the nurses have a cell

phone. Each of the nurses has a cell phone.

Many indefinite pronouns are singular i.e. another, anybody, each, either, every, etc.Rule 1001.b Gregg Reference Manual: “although “s” or “es” added to a noun indicates the plural form, “s” or “es” added to a verb indicates the 3rd person singular.

The price seems reasonable. (Singular)The prices seem reasonable. (plural)

Periods and more…

Frequently physicians will dictate punctuation, do not confuse that with a word to be typed into the sentence.

The period can be dictated specifically as “period,” or “full stop.” Parentheses in full or shortened.

Not: Paren it is my personal opinion that other areas may show a more severe dysplasia paren.

But: (It is my personal opinion that other areas may show a more severe dysplasia.)

Periods Cont.

1. Give me an example of a period being used in a drug-related abbreviation or unit of measure.

2. Do you use a period(s) here: “MD”? If so, where. If not, why not?

3. For additional information see The Book of Style pages 104-108 and page 230.

Colon

1. Capitalize the word following the colon if it is normally capitalized. If it follows a section or subsection heading, or if the list or series that follows the colon includes one or more complete sentences. Do not capitalize the word following the colon if the items are separated by commas.

2. Give me an example for each of these rules.

ANSWER KEY1. The patient’s past history is as

follows: omeprazole, metoprolol, and Xanax.

2. PAST HISTORY: Negative.3. Chest x-ray revealed the

following: No cardiomegaly. No pulmonary infiltrates. Normal cardiac silhouette.

4. Chest x-ray the following: Chest x-ray revealed the following: no cardiomegaly, no pulmonary infiltrates, and normal cardiac silhouette.

ApostropheAn apostrophe (‘) is used to indicate the possessive case of nouns, to form some plurals of words, or to denote omitted letters or numbers in contractions.

1. Give me an example of an apostrophe used to show the plural of letters, symbols, lower case abbreviations, and/or single-digit numbers or terms.

2. Do I use it for upper case abbreviations also? Give me an example.

ANSWER KEY

1. ab’s, rbc’s 4 x 4’s, serial 7’s

2. RBCs, EKGs, PVCs

Adjectives

• Use a hyphen to join compound adjectives.

– a well-developed, well-nourished female

– A high-risk patient– 24-year-old white male

• DO NOT use a hyphen to join most prefixes, including the prefix “non.”

• Give me some examples of the above words that DO NOT need a hyphen.

ANSWER KEY

• Nonweightbearing, preoperative, postoperative, outpatient, nontender, noncontributory, extraocular, nearsighted, bimanual….

Capitalization

1. Capitalize brand names of drugs but not generic names. Give me some examples.

2. What are the rules for capitalizing the names of bacteria. Give me examples.

3. Do not capitalize words that indicate classification or categories except those containing a proper noun. Give me examples.

ANSWER KEY

1. Xanax (alprazolam), Lipitor (atorvastatin), Tylenol (acetaminophen)

2. Capitalize the genus but not the species name for bacteria. If the genus is abbreviated, capitalize the one-letter abbreviation, followed by a period.

– Staphylococcus aureus– E. coli

3. Examples: grade 1, stage III, Duke’s class A.

Proofreading

• On page 117 and 118 there are some great ideas for effective proofreading.

• Share your 3 favorites with the class.

The End…

• Well that’s all for today!• Thanks for joining us. • I hope you learned something to

help you in your new transcription career!

• Remember to get all of your assignments in on time! TATS are important!!

• See you next week! Same time—same.