MR260 Medical Transcription II

Week 3-Chapter 5 “Family Practice

& Critical Thinking”

Essentials of Medical Transcription

.

What You need for this class…

• Both textbooks:Essentials of Medical Transcription, A

Modular Approach, Destafano & Federman, Second Edition

AAMT Book of Style for Medical Transcription

Any other resource books you may have available such as medical dictionary, PDR, Merck Manual, etc.

How the class will work…

• This is an open book Seminar.

• Be prepared to respond to the questions on each slide.

• Be prepared to share your thoughts with the other class participants.

• After the questions slide you will see an answer slide so you can check to see how you did.

Is everyone ready?

Critical Thinking Skills

Learning to be a critical thinker is imperative in our business.

Developing critical thinking techniques ensures the accuracy and validity of your documents.

Using critical thinking techniques will help you find the answers to all the questions that will come up as you are transcribing.

Characteristics of a Critical Thinker

• Raymond S. Nickerson (1987), an authority on critical thinking, characterizes a good critical thinker in terms of knowledge, abilities, attitudes, and habitual ways of behaving. Here are some of the characteristics of such a thinker.

http://www.freeinquiry.com/critical-thinking.html

Nickerson’s Partial List…

Uses evidence skillfully and impartially. Distinguishes between logically valid and invalid inferences

[conclusions]. Can learn independently and has an abiding interest in doing

so. Is aware of the fact that one's understanding is always

limited, often much more so than would be apparent to one with a non-inquiring attitude [mind].

A Fun Definition of Critical Thinking

• Paul, Binker, Adamson, and Martin (1989)

• "the art of thinking about your thinking while you are thinking in order to make your thinking better: more clear, more accurate, or more defensible.“

• This is called “metacognating,” or thinking about what you are thinking about.

Critical Thinking Cont.

• Can you find the word “metacognating” in or through any of your resources?

• If so, where and what is the definition that they give?

• Can you give me an example of when you have caught yourself metacognating?

4 Steps to Critical Thinking

1. Identify the elements of your documenta. Body system and/or specialty

b. type of document

c. report headings, paragraph content, and the other sentences in the paragraph that you have already transcribed

d. Find the diagnosis or procedure.

e. Use any other information you may have on hand, such as the medical record or previous reports.

4 Steps to Critical Thinking

2. Evaluate your assumptions about those elementsa. Does this word, test, etc. belong in

or with this body system, procedure, operation, diagnosis?

3. Judge your choices probability or acceptability of being right.

4 Steps to Critical Thinking Cont.

4. Evaluate your choices by asking: “With what I already know, which is the most probable or likely to be correct, and why?”

Group Discussion

• Finally, After going through this and none of the things seem right, or you can’t find an answer what do you do?

NO, don’t throw your books out the window!!

Now here are some opportunities to use what you

just learned.

Exercise

• The next few slides have sentences to review.

• Using the Critical Thinking Model we just discussed choose the correct word(s) for the sentence.

H&P Family Practice

• “She noted that his BP drops at times at home going into the hundred sycosis/systolic/stasis range.”

• Hypertension and angina parous/pectoris/pectineal. MI 3 months ago.

• Medications: • Lipitor/lisinpril 10 m.g. daily

• Lopressor/lorazepam 100 m.g. BID

Answer

• She noted that his BP drops at times at home going into the hundred systolic.

• Hypertension and angina pectoris. MI 3 months ago.

• Medications: • Lisinpril 10 m.g. daily

• Lopressor 100 m.g. BID

Answer the multiple choice questions below:

1. Accumulation of fluid and cellular debris in the tissues:1. Exdate

2. Exudate

3. Edema

4. Exdema

2. Inflammation of the mucous membrane of the nose1. Mucosa

2. Mucos

3. Rhinitis

4. rinitis

ANSWERS

1. Accumulation of fluid and cellular debris in the tissues:1. Exudate

2. Inflammation of the mucous membrane of the nose1. Rhinitis

Group Discussion

• How did you do?

• Give me some idea of why you chose one thing over the other, especially in question 1 where the two words exudate and edema are so close?

Chart Note Family Practice

• SUBJECTIVE: The patient comes in still complaining of mid-upper gastric pain. She denies any hematemesis/chemotaxis or melena/heloma.

• OBJECTIVE: Her skin pallor/pallium is normal. The abdomen is soft, slightly tender in the epigastric/epiglottis region. There is no rigidity/depilatory or rebound.

Answer

• SUBJECTIVE: The patient comes in still complaining of mid-upper gastric pain. She denies any hematemesis or melena.

• OBJECTIVE: Her skin pallor is normal. The abdomen is soft, slightly tender in the epigastric region. There is no rigidity or rebound.

Group Discussion

How did you do? Give me some idea of why you chose one thing over the other?

Will this lesson help you in the future? How?

The End• Well that’s all for tonight! Next week we’ll

do some more metacognating!!

• Thanks for joining us. I hope you learned something to help you in your transcription career.

• I’m feeling a little bewitched

after this class!

• See you next week! Same time—same place!