Hillcrest Medical Center Beginning Medical Transcription Course

by Ireland, Patricia; Novak, Mary Ann

• ISBN13: 9781401841089
• ISBN10: 1401841082
• Edition: 6th
• Format: Paperback
• Copyright: 2004-06-24
• Publisher: CENGAGE Delmar Learning

Summary

This best-selling transcription book is now printed in full color, enhancing the anatomical illustrations presented. The book and practice software create a simulation approach, giving learners a working knowledge of the medical reports most commonly used in hospital and ambulatory care settings. Learners transcribe a variety of reports from inpatient case studies taken from actual medical reports. Organized by body system, reports transcribed include history and physical examination, operative, pathology, radiology, and discharge summary.

Table of Contents

Preface	v
Prerequisites	v
Course Description	v
Objectives	vi
Student Text-Workbook	vi
Instructor's Manual	viii
About the Authors	ix
Section 1 Introduction	1	(14)
Welcome to Hillcrest Medical Center	2	(1)
Confidentiality Policy	3	(1)
Legal Issues	3	(1)
Health Insurance Portability and Accountability Act (HIPAA)	3	(1)
Objectives	4	(1)
Length of Course	4	(1)
Transcribing Medical Reports	5	(1)
Evaluations	6	(1)
Skill-Building Exercises	6	(1)
Appendix	6	(2)
American Association for Medical Transcription	8	(4)
Medical Transcriptionist Job Descriptions	8	(1)
AAMT Code of Ethics	8	(3)
Employment and Certification Possibilities	11	(1)
Understanding Medical Records	12	(3)
History and Physical Examination (H&P)	12	(1)
Radiology Report	12	(1)
Operative Report	13	(1)
Pathology Report	13	(1)
Request for Consultation	13	(1)
Discharge Summary	13	(1)
Death Summary	13	(1)
Autopsy Report	14	(1)
Outpatient Model Reports	14	(1)
Section 2 Model Report Forms	15	(24)
Section 3 References	39	(24)
Transcription Rules for Hillcrest Medical Center and Quali-Care Clinic	40	(8)
Style Variations	40	(1)
Capitalization	41	(1)
Numbers	42	(1)
Punctuation	43	(1)
Abbreviations and Symbols	44	(2)
List of Metric Measurements	46	(1)
The Grammar of Microbiology	46	(1)
Vital Signs	47	(1)
CMTips™	48	(3)
Difficult Singular and Plural Words and Phrases	48	(1)
Temperature versus Fever	48	(1)
A Tongue Twister	48	(1)
Dermatology Terms	48	(1)
Pulmonary Terms	48	(1)
Race	48	(1)
Age	48	(1)
Zero Safety	49	(1)
Roman Numerals	49	(1)
Time	49	(1)
Abduction versus Adduction	49	(1)
Class and Stage	49	(1)
Connective Tissues	49	(1)
Subjective versus Objective	49	(1)
Surgical Terms	49	(1)
Gynecology Terms	50	(1)
Cardiology Terms	50	(1)
Jr, Sr, II, and III	50	(1)
Using the Student Activities CD-ROM	51	(2)
Report Formatting Guidelines	51	(1)
Common Microsoft Computer Commands	52	(1)
Voice Recognition Technology	52	(1)
Understanding Medical Terminology	53	(10)
Principles	53	(1)
Prefixes/Pronunciation	54	(2)
Combining Forms	56	(4)
Suffixes	60	(3)
Section 4 Case Studies	63	(48)
Case 1 The Reproductive System	64	(1)
Glossary	65	(4)
Case 2 The Musculoskeletal System	69	(1)
Glossary	70	(3)
Case 3 The Cardiopulmonary System	73	(1)
Glossary	74	(4)
Case 4 The Integumentary System	78	(1)
Glossary	79	(3)
Case 5 The Urinary System	82	(1)
Glossary	83	(2)
Case 6 The Nervous System	85	(1)
Glossary	86	(7)
Case 7 The Digestive System	93	(1)
Glossary	94	(3)
Case 8 The Endocrine System	97	(1)
Glossary	98	(3)
Case 9 The Lymphatic System	101	(1)
Glossary	102	(4)
Case 10 The Respiratory System	106	(1)
Glossary	107	(4)
Section 5 Quali-Care Clinic	111	(52)
Welcome to Quali-Care Clinic	112	(1)
Quali-Care Clinic Report Log	113	(1)
Outpatient Reports	114	(1)
Report 1 Gynecology Operative Report	114	(3)
Report 2 Pathology Report	117	(2)
Report 3 Cytology Report	119	(1)
Report 4 Oncology Consult	120	(2)
Report 5 Infectious Disease Soap Note	122	(3)
Report 6 Pulmonology Procedure Note	125	(2)
Report 7 Oncology Consult	127	(3)
Report 8 Correspondence	130	(1)
Report 9 Infectious Disease Consult	131	(2)
Report 10 Pediatrics---Emergency Center Report	133	(2)
Report 11 Internal Medicine History and Physical	135	(2)
Report 12 Psychiatry Consult	137	(1)
Report 13 Radiology---Echocardiogram Report	138	(2)
Report 14 Radiology---Colonoscopy Procedure Note	140	(2)
Report 15 Radiology---CT Scan of Abdomen	142	(1)
Report 16 Infectious Disease HPIP Note	143	(2)
Report 17 Radiology---Mammogram and CT Scan of Abdomen	145	(2)
Report 18 Oncology Consult	147	(2)
Report 19 Correspondence	149	(1)
Report 20 Pulmonology---Sleep Study	150	(3)
Report 21 Psychiatry Consult	153	(1)
Report 22 Radiology---MRI	154	(3)
Report 23 Pediatrics---Emergency Center Report	157	(2)
Report 24 Hematology Consult	159	(2)
Report 25 Correspondence	161	(2)
Section 6 Skill Building Exercises	163	(26)
Crossword Puzzles 1 through 6	164	(6)
Proofreading Exercises 1 through 10	170	(19)
Appendix	189	(24)
Proofreader's Marks	190	(1)
Challenging Medical Words, Phrases, Prefixes	191	(4)
Sample Patient History Form	195	(2)
The Lund Browder Chart	197	(1)
Laboratory Test Information	198	(3)
Sample Forms for Ordering Laboratory Tests, Radiology Tests and Consults, Medical Supplies	201	(8)
Building a Reference Library	209	(1)
Web Sites for Transcriptionists	209	(1)
General Interest Web Sites	209	(1)
``A Healthcare Controlled Vocabulary''	210	(3)
Dr. Neil Davis
Index	213