Medical Transcription

We'll start by discussing the HDS's tools of the trade, reviewing a few of the reference books and the types of websites that HDSs use for research. Then, we'll look at the hardware and software used on the job. We'll talk you through downloading the free software we'll use in this course, and then we'll go through a quick tour of how to use it. By the end of this lesson, you'll be sitting at your computer, experiencing an actual medical dictation audio file, and using the Express Scribe software on your screen. As you work through the medical report, you'll practice starting, pausing, and rewinding the audio as you tap away on the keyboard.

There are nine report types that medical professionals use most often in both hospitals and clinics. In this lesson, we'll review various examples of real medical reports. We'll also do a quick review of medical correspondence. Medical letters aren't much different from traditional letters, but since you might not have typed a traditional letter in a while, a refresher might be nice. We'll finish the lesson with some specific tips about pathology reports and how to handle numbers and measurements. Then, you'll practice transcribing a medical letter and a pathology report.

We'll spend this lesson reviewing how to listen most effectively and discussing the difference between hearing and active listening. We'll also touch on many issues that keep voice recognition systems from replacing humans, including homonyms, synonyms, and antonyms. Then, we'll discuss how you can use phonetics and vowel sounds (as well as a few other tricks!) to help you figure out a word or phrase in a muddled recording. Then we'll talk a bit about the radiology department and radiology reports and finish by practicing transcribing one in today's assignment.

Lesson 5 will discuss subjects that might make you cringe a little: grammar, sentence structure, and punctuation. But this will be a painless, maybe even enjoyable, journey through some of the basic principles of writing that will help you become a better HDS. We will learn a little more about SOAP notes and then turn our attention to infectious diseases and medications. You'll also have the chance to transcribe a SOAP note and a radiology report in the lesson assignment.

We'll continue our writing examination in this lesson by discussing style from the HDS perspective. Whether transcribing or editing a document produced by voice recognition, you must follow editorial directions in spelling, capitalization, and typographical display. Those directions are the style HDSs must be concerned about. You'll be surprised at how many different ways you can treat a single word. Should it be capitalized or lowercase? Should you abbreviate it, or should you spell it out? Should your numbers be in digit form or word form? These are the issues we will cover in this lesson. Finally, we'll focus on the H&P report, and you'll have the chance to practice transcribing one.

No matter what you transcribe or edit, you can be sure that medical terminology will be a huge part of it. That's what we'll be focusing on today. Dictators aren't perfect. They might say one word when they actually mean another. Or they might say a word that has a sound-alike word, like anuresis and enuresis. If you understand medical terminology well, you can pinpoint the correct word to ensure your transcription is accurate. Then, we will review the basic nature of heart disease and its treatment. We'll also take a close look at another common disease: diabetes.

A critical component of the HDS's work is how you put your reports together. So, we'll talk about how to break up your reports into sections with headings, subheadings, special line spacing, page breaks, and other formatting niceties. We'll also look closer at ways you can make your work easier by using word processing shortcuts, AutoText, macros, and templates. Mastering them will make you a faster and more efficient HDS! We will also focus on surgical reports. Surgical terminology is important to know, and it's also fascinating to take a look at what goes on in the operating room. The assignment for this lesson will include a surgical report to help you put to work all the new knowledge you've gained.

Another essential step in healthcare documentation is editing and proofreading your work; that's what we'll concentrate on today. We will start by sharing some editing do's and don'ts and what to look for when proofreading. We will cover a disease process that has affected virtually everyone in some way: cancer. Once you have an overview of cancer, we'll work on the consultation report. Physicians often ask specialists to evaluate their patients, especially cancer patients, further. So, this is a common report you'll likely transcribe regularly. The lesson assignment includes a consult report to transcribe, and you'll also get to practice proofreading.

So far, we've focused on the mechanical elements of medical transcription. But there is still a lot you need to know about clinical issues. So, this will be an entirely clinical lesson. We'll talk about classification systems and their transcription foibles. Plus, now that you have the bones of grammar and style down, we'll talk about some real bones. We'll begin by discussing fractures and spine levels. Finally, we'll discuss discharge and death summaries. They are very similar reports, but we'll examine some subtle differences.

This lesson will be similar to the last in that it covers many clinical issues. It won't all be clinical, however. There are a few miscellaneous things to cover. They don't fit into neat categories, so they are all put here. Once we finish with these miscellaneous items, we'll jump back into some clinical issues, talking specifically about infections. Then, we'll focus on smaller components of the body: cells and blood. You'll notice how everything you've learned can come together in an autopsy report. This is probably the longest, most comprehensive report you'll come across. Of course, you'll also have the chance to transcribe an autopsy report in the assignment!

By now, you have the tools and the knowledge you need to dip your toe into the waters of healthcare documentation. But there are still a couple of big questions to answer. How do you manage your workload? Also, how do you establish yourself as a medical transcriptionist, and do you need more training? This lesson will discuss the various ways you can work—everything from being an independent contractor all the way up to consultant work. We'll talk about additional training as well. Then, you'll take a peek at why this is an exciting time to enter the medical transcription field. You will look at some details about working in related fields, such as document integrity specialist, EHR specialist, and scribe.