Medical Transcription
Techniques and Procedures
- 7th Edition - March 2, 2011
- Imprint: Saunders
- Author: Marcy O. Diehl
- Language: English
- Paperback ISBN:9 7 8 - 1 - 4 3 7 7 - 0 4 3 9 - 6
- Paperback ISBN:9 7 8 - 0 - 3 2 3 - 3 1 8 5 8 - 7
- eBook ISBN:9 7 8 - 1 - 4 5 5 7 - 0 8 4 8 - 2
- eBook ISBN:9 7 8 - 0 - 3 2 3 - 5 1 1 5 9 - 9
Master the fundamentals of medical transcription and meet the challenges of the evolving medical transcription field with Medical Transcription: Techniques and Procedures, 7th E… Read more
Purchase options
Institutional subscription on ScienceDirect
Request a sales quoteMaster the fundamentals of medical transcription and meet the challenges of the evolving medical transcription field with Medical Transcription: Techniques and Procedures, 7th Edition. Respected authority Marcy O. Diehl delivers proven, practical training in the skills and technology essential to your success, including proofreading, editing, speech recognition technology, and more. This new edition also reflects an increased emphasis on medical editing and other related fields to keep you current with the changing medical transcription profession and fully prepare you for your role in health information management.
- Comprehensive coverage and practical exercises demonstrate fundamental editing/transcription concepts and boost your proficiency in:
- Punctuation
- Capitalization
- Numbers
- Abbreviations and symbols
- Word endings
- Formation of plural forms
- Exercises and helpful hints enhance your proofreading and editing skills and help you prevent common errors.
- Extensive practice and review exercises on Evolve reinforce your understanding and give you the experience to confidently move into the transcription workforce.
- Title of Book
- Cover image
- Title page
- Table of Contents
- Copyright
- Dedication
- Preface
- Evolve Companion Website
- For the Student
- For the Instructor
- Acknowledgments
- Section One. Career Role and Responsibilities
- Chapter 1. The Medical Transcriptionist’s Career, Including Ethical and Legal Responsibilities
- Introduction
- Basic skills and interests
- Medical Communication
- Job opportunities
- Job descriptions
- Transcription Skills
- Transcription Speed
- Physically Challenged Transcriptionists
- Association For Healthcare Documentation Integrity
- The AHDI Code of Ethics for Medical Transcriptionists
- Membership
- Certification for Medical Transcriptionists
- Health Professions Institute
- Ethical And Legal Responsibilities
- Confidentiality
- Health Insurance Portability and Accountability Act of 1996
- Risk Management
- Medical Reports and Records
- Authentication of Documents
- Manual Signatures
- Electronic Signatures
- Medicare Signature Requirements
- Joint Commission Signature Requirements
- Abbreviations, Acronyms, and Slang
- Deadlines and Turnaround Time for Medical Reports
- Turnaround Time Expectations
- Dates of Documents
- Completeness of Medical Reports
- Ownership
- Corrections
- Medical Records
- Electronic Health Record
- Electronic Medical Record
- Right to Privacy
- Privileged Communication
- Release of Medical Records
- Guidelines for Release of Information
- Special Guidelines for Release of Hospital Information
- Retention of Records
- Subpoena Duces Tecum
- Professionalism
- Transcriptionist’s Notebook Or File
- Directions
- Note
- Directions
- Directions
- Name: ____________________________________________Score:__________
- Section Two. Tools of Transcription
- Chapter 2. Equipment and Technology
- History
- Dictation
- Digital Dictation
- Computer Systems
- Hardware
- Data Communications and Modems
- Computer Maintenance
- Software
- Speed Typing Systems
- Text Expansion
- AutoCorrect
- Macros
- Online Information Processing Systems
- Data Storage
- Hard Drive
- Compact Disks
- Zip Drives, Flash Media, and Other Removable Drives
- Data Backup
- Printer
- Ergonomics
- Dictation Equipment
- Speech Recognition Technology
- Front-End Speech Recognition
- Back-End Speech Recognition
- Dictation Media
- Hand/Foot Control
- Dictation
- Maintenance
- File Maintenance
- Cassette Tape Transcriber
- Transcription Preparation
- Equipment For The Physically Challenged Transcriptionist
- Fax Machines
- Digital Scanners
- Electronic Signatures
- Disposal of Electronic Media
- Directions
- Section Three. Transcription Guidelines
- Chapter 3. Punctuation
- Introduction
- Vocabulary
- Directions
- The comma
- Directions
- Directions
- Directions
- Directions
- Directions
- Directions
- Rule Review
- Directions
- Directions
- The Period and Decimal Point
- The semicolon
- The colon
- Directions
- Directions
- Rule Review
- Example
- The hyphen
- The dash
- The apostrophe
- Quotation Marks
- Parentheses
- The Slash (Also Called The Bar, Virgule, Or Diagonal)
- Spacing With Punctuation
- Directions
- Directions
- Rule Review
- Example
- Directions
- Directions
- Directions
- Directions
- Punctuation rule synopsis
- Chapter 4. Capitalization
- Introduction
- Vocabulary
- Rules
- Directions
- Directions
- Directions
- Directions
- Directions
- Capitalization Rule Synopsis
- Directions
- Chapter 5. Transcribing Numbers, Figures, and Abbreviations
- Introduction
- Use of the Metric System In Medical Records
- Rules to Follow in Typing Metric Measurements
- Exceptions
- Typing Numbers
- Ordinal Numbers: First, Second, Third, and So On
- Numbers Spelled Out or Written as Words: One, Two, Three, and So On
- Numbers as Figures: 1, 2, 3, and So On
- Subscript and Superscript
- Mixed Numbers
- Unrelated Numbers and Other Combinations
- Spacing
- Directions
- Directions
- Roman Numerals
- Directions
- Directions
- Use of Symbols
- Use of Abbreviations, Acronyms, Initialisms, And Brief Forms
- Typing Drugs
- Abbreviation Reference
- Directions
- Directions
- Example
- Directions
- Directions
- Directions
- Postscript
- Symbol and Number Rule Synopsis
- Directions
- Directions
- Chapter 6. Letter Transcription
- Introduction
- Qualities of A Mailable Letter
- Letter formats
- Item 1: Paper
- Item 2: Letterhead
- Item 3: Date
- Item 4: Inside Address
- Item 5: Street Address
- Item 6: City and State
- Item 7: Salutation
- Item 8: Body
- Item 9: Complimentary Close
- Item 10: Typed Signature Line
- Item 11: Reference Initials
- Item 12: Enclosure Notation
- Item 13: Distribution Notation
- Other Letter Mechanics
- Blind Copy
- Postscript
- Attention Line
- To Whom It May Concern
- Reference Line
- Full-Block Placement (see Figure 6-1, A)
- Modified Block Placement
- Modified Block Placement (see Figure 6-1, B)
- Personal Or Confidential Notation
- Two-page letters
- Copies
- File Notation
- Placement
- Directions:
- DIRECTIONS:
- Paragraphing
- Directions:
- DIRECTIONS:
- Directions:
- DIRECTIONS:
- Envelope preparation
- DIRECTIONS:
- Signing and Mailing
- A Final Note
- Food for thought
- Example
- Chapter 7. Proofreading, Making Corrections, and Quality Assurance
- Introduction
- Where Errors Occur
- Accuracy
- Quality assurance
- Types Of Errors
- Critical Errors
- Major Errors
- Minor Errors
- Rules for Recognizing and Avoiding Errors
- Editing
- Grammar
- Inconsistencies, Redundancies, and Technical Errors
- Abbreviations
- Misunderstandings
- Flagging
- Slang, Vulgar, and Inflammatory Remarks
- Simple Editing
- “Distance” Errors
- Scoring Methods (Figures 7-3 and 7-4)
- Directions
- How to Proofread
- Proofreader’s Marks
- Spacing
- Delete
- Insert Bottom Punctuation
- Insert Top Punctuation
- Insert a Period
- Insert a Hyphen
- Insert a Word
- Transpose
- Let It Stand
- Use Capital Letters
- Use Small (Lowercase) Letters
- Spelling
- Paragraphing
- Move the Text
- Directions
- Directions
- Directions
- Directions
- Proofreading and Editing
- Directions
- Chapter 8. Using Reference Books: Learn How to Get Help from the Experts
- Introduction
- The English Dictionary
- The Medical Dictionary
- Cross-Reference
- Directions
- Medical Word Books and Medical Spellers
- Using reference books
- Directions
- Reference Book List
- Software Spellchecker
- Journals And Newsletters
- Medical Spelling
- Directions
- Compound words
- Combining Forms
- Directions
- Directions
- French Medical Words
- Spelling The Names Of Drugs
- Reliable Drug Reference Books
- Physicians’ Desk Reference (PDR)
- Clinical Pharmacology
- American Drug Index and Quick Look Drug Book
- The Saunders Pharmaceutical Word Book
- Directions
- Directions
- Drug Name Phonetics
- Websites
- Professional Organizations
- Hospital List
- Drug References
- Sutures
- Encyclopedias, Dictionaries, Thesauruses, Quotations
- Medical Questions
- Directions
- Laboratory Terminology and Normal Values
- Directions
- Classroom Group Research Skills Test
- Directions
- Chapter 9. Word Endings: Plurals, Nouns, and Adjectives
- Introduction
- Vocabulary
- Plural Endings
- Forming Plurals Of Medical Terms
- Directions
- Directions
- Directions
- Directions
- Directions
- Directions
- Exceptions to Rules for Plural Ending
- The words in the following list form plurals in irregular ways
- Basic Rules For Plural English Words
- Directions
- Noun Endings
- Adjective Endings
- Directions
- Directions
- Directions
- Directions
- Directions
- Chapter 10. Grammar Review
- Introduction
- Homonyms And Other Confusing Word Pairs
- Directions
- Word-Choice Pairs
- Affect-Effect
- Directions
- A–An
- Abduction–Adduction–Addiction
- Abrasion–Aberration
- Absorption–Adsorption–Abruption
- Accept–Except
- Adapt–Adopt
- Adherence–Adherents
- Advise–Advice
- Aid–Aide
- Allusion–Illusion
- Already–All Ready
- Alternately–Alternatively
- Altogether–All Together
- Apposition–Opposition
- Appraise–Apprise
- Assure–Ensure–Insure
- Awhile–A While
- Bad–Badly
- Beside–Besides
- Bolus–Bullous
- Breech–Breach
- Bridle–Bridal
- Checkup–Check Up
- Chord–Cord
- Cite–Sight–Site
- Compare To–Compare With
- Complement–Compliment
- Continual–Continuous
- Devise–Device
- Dilate–Dilation–Dilatation
- Disc–Disk
- Discrete–Discreet
- Disinterested–Uninterested
- Dysphagia–Dysphasia–Dysplasia
- Elicit–Illicit
- e.g.–i.e
- Emigrate–Immigrate (Emigrant–Immigrant)
- Eminent–Imminent–Immanent
- Enervated–Innervated
- Etiology–Ideology
- Every Day–Everyday
- Every One–Everyone
- Directions
- Farther–Further
- Fewer–Less
- Followup–Follow Up–Follow-up
- Formerly–Formally
- Imply–Infer
- In Toto–Total
- Incidence–Incidents
- Last–Latest
- Lie–Lay
- Like–As If
- Lose–Loose
- Maybe–May Be
- Most–Majority
- Nauseated–Nauseous
- Navel–Naval
- Directions
- Only One of–The Only One of–One of
- Opposition
- Palette–Palate–Pallet
- Past–Passed
- Persons–People
- Plane–Plain
- Principle–Principal
- Proceed–Precede
- Recur–Reoccur
- Regardless–Irregardless
- Regime–Regimen–Regiment
- Repeat–Repeated
- Root–Route
- Sit–Sat–Set
- Sight–Site–Cite
- Sometime–Some Time–Sometimes
- Super–Supra
- Then–Than
- Tortuous–Torturous
- Worse–Worst
- Directions
- Which–That
- Who–Whom
- Who–Whom and Verb Forms with Only One of–The Only One of–One of
- Workup–Work Up
- Directions
- Directions
- Adjective Modifiers
- Antecedents
- Collective Nouns
- Dangling Constructions And Misplaced Modifiers
- Indefinite Pronouns And Verbs
- Parallel Structure
- Personal Pronouns
- Pronouns Used as the Subject of the Sentence: I, You, He, She, We, They
- Pronouns Used as the Objects of Verbs and Prepositions: Me, You, Him, Her, Us, Them
- Pronouns and Contractions
- Reflexive Pronouns: Myself, Herself, Ourselves, Yourself, Himself, Itself, Yourselves, Themselves
- Plurals and Singulars
- Plural Pronouns with Singular Antecedents
- Sentence Structure
- Tense of Verbs
- Proper Terms for Persons
- Directions
- Directions
- Section Four. Medical Records and Reports
- Chapter 11. Outpatient Medical Chart Notes and Daily Progress Notes
- Introduction
- General Principles For Complete Documentation In Medical Records
- History
- Examination
- Medical Decision Making
- Counseling and Coordination of Care
- New Patient, Office
- Established Patient, Office
- Chart Note, Emergency Department Visit
- Transcription Hints
- Making Corrections
- Directions
- Directions
- Directions
- Directions
- Directions
- Directions
- Directions
- Directions
- Directions
- Chapter 12. Preparation of a History and Physical Examination Report
- Introduction
- Formats and Styles
- Basic Block Format Report Style
- Modified Block Format Report Style
- Run-on Modified Block Report Style
- Tabulated Block Report Style
- The History
- Statistical Data
- Chief Complaint
- Present Illness
- Past History
- Habits
- Diseases
- Operations
- Allergies
- Social History
- Gynecologic (When the Patient Is a Woman)
- Family History
- Review of Systems
- Skin
- Hair
- Heent
- Cardiorespiratory (CR)
- Gastrointestinal (GI)
- Genitourinary (GU)
- Gynecologic (GYN)
- Neuropsychiatric (NP)
- Musculoskeletal (MS)
- Directions
- Directions
- The Physical Examination
- Physical Examination, Basic Block Format
- History and Physical, Run-On Format
- Physical Examination, Tabulated Block Format
- Physical Examination, Indented Format
- The Outline
- General
- Vital Signs
- HEENT (or Head and Neck)
- Head
- Eyes
- Ears
- Nose
- Mouth and Throat
- Neck
- Chest
- Lungs
- Heart
- Abdomen
- Genitalia (or Pelvic or Genitourinary)
- Rectal
- Extremities
- Neurologic
- Diagnosis (Impression, Assessment, or Conclusion)
- Note
- Treatment (or Recommendation)
- the Data
- Directions
- Directions
- Directions
- Directions
- Using Figure 12-1
- Using Figure 12-8
- Using Figure 12-9
- Using Figure 12-10
- Using Figures 12-1, 12-2, 12-3, and 12-4 (All Have Identical Material)
- Directions
- Short-Stay Record
- Interval History
- Directions
- Directions
- Chapter 13. Preparation of Miscellaneous Medical Reports
- Introduction
- Discharge Summaries
- Operative Reports
- Pathology Reports
- Radiology and Imaging Reports
- Consultation Reports
- Autopsy Protocols
- Medicolegal Reports
- Patient Identification
- Date of Accident or Work-Related Injury
- History
- Present Complaints
- Past History
- Physical Findings
- Laboratory or X-Ray Findings
- Diagnosis
- Prescribed Therapy
- Patient’s Disability
- Prognosis
- Physician’s Statement
- Psychiatric Reports
- Directions
- Directions
- Directions
- Directions
- Directions
- Directions
- Directions
- Directions
- Directions
- Section Five. Correspondence and Business Documents
- Chapter 14. Writing Business Documents: Email, Memos, Agendas, Minutes, and Policies
- Introduction
- Composition Guidelines
- Writing Sentences
- Sentence Fragments
- Run-on Sentences
- Parallel Structure
- Dangling Constructions
- Unnecessary or Repetitious Words
- Directions
- Planning and Writing Paragraphs
- Opening Topic
- Transitions
- Second Paragraph
- Final Sentence
- Beginning to Write
- Body of the Document
- Closing of the Document
- Writing Memoranda
- General Format
- Preprinted and Computer-Formatted Macros
- Typed Format
- Vertical
- Horizontal
- Closing Elements
- Continuations
- Getting Started Writing
- Composing Example
- Review of Your Document
- Electronic Mail
- Attachments
- Confidentiality
- Content
- Copies
- Distribution Lists
- Etiquette
- Response
- Directions
- Typing Hospital Protocols and Reports
- Headings and Outline
- Lists
- Multipage Reports
- Closing Format
- Agenda
- Directions
- Minutes
- Title
- Date, Time, and Place
- Names of the Members
- Format
- Lists
- Closing
- Distribution
- Outlines
- Reference Materials
- Directions
- Directions
- Directions
- Directions
- Chapter 15. Making the Transition from MT to Speech Recognition Editor
- Introduction
- Medical Transcriptionist Terminology
- Professional Level 1
- Knowledge, Skills, and Abilities
- Professional Level 2
- Knowledge, Skills, and Abilities
- Professional Level 3
- Knowledge, Skills, and Abilities
- Knowledge, Skills, and Abilities
- Medical Document Quality Editor Terminology
- Speech-Recognized Draft Editing
- Guidelines
- Demographic Data
- Facility Specifics
- Format and File Type
- Critical Thinking
- Directions
- Directions
- Speech Recognized Draft Editing Skills
- Letting Go
- Directions
- Directions
- Chapter 16. Establishing Your Career and Applying for Transcription Positions
- Introduction
- Working From Home
- The Remote-Based Work Site
- The Home-Based Entrepreneur
- Terminology for Home-Based Workers
- Employee
- Statutory Employee
- Independent Contractor
- Marketing Yourself
- The Home-Based Business
- Office Space
- Equipment
- Records and Finances
- Emotional Needs
- Professional Considerations and Work Ethics
- Business
- Qualities
- Developing Clientele
- Professional Fees
- Subcontracting
- Opportunities For Employment
- Electronic Job Search
- Your Resumé
- Cover Letters
- Temporary Jobs
- Interview Skills
- Prepare for the Interview
- The Interview
- Telephone Interview
- Personal Interview
- Portfolio
- After the Interview
- Application Forms
- Professionalism
- Tips For Holding A Job
- Job Description
- How To Leave A Job
- Direct Compensation
- Employee Benefit Plans Fully or Partially Paid By Employer—Insured
- Employee Benefit Plans—Uninsured
- Retirement Contributions
- Miscellaneous
- Directions
- Directions
- Directions
- Directions
- Section Six. Appendices
- Appendix A. Answers to Tests
- Answers to 3-1: Self-Study
- Answers to 3-2: Self-Study
- Answers to 3-3: Self-Study
- Answers to 3-4: Self-Study
- Answers to 3-6: Self-Study
- Answers to 3-7: Self-Study
- Answer to 3-8: Practice Test
- Answers to 3-10: Self-Study
- Answers to 3-11: Self-Study
- Answers to 3-12: Self-Study
- Answers to 3-13: Self-Study
- Answers to 3-14: Self-Study
- Answers to Chapter 3: Let’s Have a Bit of Fun
- Answers to 4-1: Self-Study
- Answers to 4-2: Self-Study
- Answer to 4-3: Self-Study
- Answers to 5-1: Self-Study
- Answers to 5-2: Practice Test
- Answers to 5-3: Self-Study
- Answers to 5-4: Practice Test
- Answers to 5-6: Self-Study
- Answers to 5-7: Practice Test
- Answers to 5-8: Self-Study
- Answers to 6-3: Self-Study
- Answers to 6-4: Self-Study
- Answers to 6-6: Typing Practice Test
- Answers to 7-1: Self-Study
- Answer to 7-2: Self-Study
- Answer to 7-3: Self-Study
- Answer to 7-4: Typing Practice Test
- Answers to 7-5: Self-Study
- Answers to 8-1: Self-Study
- Answers to 8-2: Practice Test
- Answers to 8-3: Practice Test
- Answers to 8-4: Self-Study
- Answers to 8-5: Self-Study
- Answers to 8-6: Practice Test
- Answers to 9-1: Self-Study
- Answers to 9-2: Self-Study
- Answers to 9-3: Self-Study
- Answers to 9-4: Self-Study
- Answers to 9-5: Practice Test
- Answers to 9-6: Self-Study
- Answers to 9-7: Self-Study
- Answers to 9-8: Self-Study
- Answers to 10-1: Diagnostic Test
- Answers to 10-2: Self-Study
- Answers to 10-3: Self-Study
- Answers to 10-4: Self-Study
- Answers to 10-5: Self-Study
- Answers to 10-6: Self-Study
- Answers to 10-7: Practice Test
- Answers to 10-8: Practice Test
- Answer to 11-1: Self-Study
- Answer to 11-2: Practice Test
- Answer to 11-5: Self-Study
- Answers to 11-9: Self-Study
- Answer to 12-1: Self-Study
- Answer to 12-2: Practice Test (Tabulated Block)
- Answer to 12-5: Practice Test
- Answers to 12-6: Self-Study
- Answer to 13-1: Self-Study
- Answers to 13-4: Self-Study
- Answers to 14-1: Self-Study
- Answers to 14-2: Self-Study
- 1 Possible Outline
- 1 Email
- 2 Possible Outline
- 2 Email
- Answers to 14-3: Self-Study
- Agenda
- Answers to 14-4: Self-Study
- Appendix B. Reference Materials
- Introduction
- Contents
- Abbreviations Commonly Used
- Drugs Most Often Prescribed—Top 200 Drug List 2009
- Genus and Species Names Commonly Used∗
- Homonyms
- Everyday Homonyms
- Medical Homonyms
- Laboratory Terminology and Normal Values
- Laboratory Terms and Symbols
- Computerized Examinations
- Writing Laboratory Values
- Normal Values
- Hematology Vocabulary
- Hematology Tests and Values
- Corpuscular Values of Erythrocytes (Indices)
- Blood Gases
- Coagulation Tests
- Differential
- Morphology
- Chemistry
- Immunoglobulins (Ig), Serum
- Radioassays for Thyroid Functions
- Serology
- Urinalysis Vocabulary
- Urinalysis Tests and Values
- Physical Examination and Chemical Tests
- Microscopy
- Crystals Found in Acid Urine
- Crystals Found in Alkaline Urine
- Plural Forms
- Short Forms, Brief Forms, and Medical Slang
- Sound and Word Finder Table
- State Names and Other us Postal Service Abbreviations
- Two-Letter State Abbreviations for the US and Its Dependencies
- Two-Letter Abbreviations for Canadian Provinces and Territories
- Trademarked Forms (Packaging, Dosage Forms, and Delivery Systems) Used with Drug Names∗∗Compiled from Drake E: Saunders Pharmaceutical Word Book 2010, St Louis, 2010, Saunders.
- Unusual Medical Terms Commonly Dictated in Medical Reports
- Appendix C. Medical Documents
- Contents
- Supplementary data
- Appendix D. Rules and Helpful Hints for Transcribing
- Dictation Sets For Students
- Set 1: Reference Notes for Beginning Transcription on the Evolve Website
- Set 2: Speech Recognition Dictated Reports in Electronic Format on the Evolve Website
- Facility and Place Names
- Format Requirements
- Set 3: Electronic Dictation of 99 Actual Medical Reports on the Evolve Website
- Index
- Punctuation rule synopsis
- Capitalization Rule Synopsis
- Edition: 7
- Published: March 2, 2011
- Imprint: Saunders
- No. of pages: 560
- Language: English
- Paperback ISBN: 9781437704396
- Paperback ISBN: 9780323318587
- eBook ISBN: 9781455708482
- eBook ISBN: 9780323511599
MD
Marcy O. Diehl
Affiliations and expertise
Professor Emeritus, Medical Transcriptionist Specialist Curriculum, Grossmont Community College, El Cajon, California