Diehl and Fordney's Medical Transcribing: Techniques and Procedures / Edition 5

Diehl and Fordney's Medical Transcribing: Techniques and Procedures / Edition 5

by Marcy O. Diehl, Marilyn Takahashi Fordney
     
 

ISBN-10: 072169568X

ISBN-13: 9780721695686

Pub. Date: 10/02/2002

Publisher: Elsevier Health Sciences

This practical text provides an understanding of how medical documents work and how to create them accurately. Emphasizing medical and English grammar, it explains fundamental concepts on every aspect of medical transcription - including the various formats used in transcribing letters, chart notes, emergency room notes, history and physical exams, and operative

Overview

This practical text provides an understanding of how medical documents work and how to create them accurately. Emphasizing medical and English grammar, it explains fundamental concepts on every aspect of medical transcription - including the various formats used in transcribing letters, chart notes, emergency room notes, history and physical exams, and operative and specialty reports. This fifth edition provides a wealth of exercises that reinforce the material in the text, as well as a complete review of grammar, punctuation, capitalization, symbol use, reference research, plural forms, the various equipment used in medical transcription, and the legal aspects of medical records.
• Content on grammar skills demonstrates the correct use of punctuation, capitalization, numbers, abbreviations and symbols, word endings, formation of plural forms, and more — with numerous practice exercises to provide the fundamental knowledge necessary to work in the field.
• Authentic medical transcription documents illustrate how to set up special formats for medical office charts, history and physical exams, operative reports, x-ray reports, and pathology reports.
• Exercises and helpful hints allow readers to practice their proofreading and editing skills.
• Skill drills using the medical dictionary, drug references, and laboratory values demonstrate how to find and use references.
• A chapter on Equipment explains how to operate the equipment used in the workplace and how to make informed decisions when purchasing equipment for personal use.

Product Details

ISBN-13:
9780721695686
Publisher:
Elsevier Health Sciences
Publication date:
10/02/2002
Edition description:
Older Edition
Pages:
608
Product dimensions:
8.52(w) x 10.94(h) x 1.03(d)

Table of Contents

Career Role and Responsibilities
1The Medical Transcriptionist's Career, Including Ethical and Legal Responsibilities3
Note From the Author4
Introduction4
Medical Communication4
Job Opportunities4
Job Descriptions5
Transcription Skills8
Medical Records8
Transcription Speed8
Physically Challenged Transcriptionists9
Certification for Medical Transcriptionists9
Ethical and Legal Responsibilities10
Confidentiality14
Transcriptionist's Notebook or File22
Tools of Transcription
2Equipment and Technology27
Note From the Author28
History28
Computer Systems30
Ergonomics33
Dictation Equipment33
Hand/Foot Control36
Dictation37
Maintenance38
Transcription Preparation39
Equipment for the Physically Challenged40
Facsimile Machines41
Vocabulary42
Transcription Guidelines
3Punctuation47
Note From the Author48
Introduction48
Vocabulary48
The Comma55
The Period and Decimal68
The Semicolon68
The Colon69
The Hyphen72
The Dash75
The Apostrophe75
Quotation Marks78
Parentheses79
The Slash (Also Called the Bar or Diagonal)80
Spacing80
Punctuation Rule Synopsis86
4Capitalization93
Introduction94
Vocabulary94
Rules94
Capitalization Rule Synopsis105
5Transcribing Numbers, Figures, and Abbreviations109
Introduction110
Typing Numbers110
Use of Symbols121
Use of Abbreviations, Acronyms, Initialisms, and Brief Forms122
Abbreviation Reference126
Postscript130
Symbol and Number Rule Synopsis130
6Letter Transcription135
Note From the Author136
Introduction136
Vocabulary136
Letter Formats137
Qualities of a Mailable Letter142
Two-Page Letters151
Copies151
File Notation151
Placement152
Paragraphing153
Envelope Preparation157
7Making Proofreading Corrections, and Quality Assurance163
Note From the Author164
Introduction164
Where Errors Occur164
Accuracy165
Types of Errors165
Editing169
Flagging172
How to Proofread176
Proofreader's Marks179
8Using Reference Books: Learn How to Get Help From the Experts191
Note From the Author192
Introduction192
The English Dictionary192
The Medical Dictionary193
Medical Word Books197
Using Reference Books197
Software Spell Checker202
Compound Words203
French Medical Words205
Spelling the Names of Drugs206
Web Sites211
Laboratory Terminology and Normal Values214
9Word Endings: Plurals, Nouns, and Adjectives219
Introduction220
Vocabulary220
Plural Endings220
Forming Plurals of Medical Terms220
Basic Plural Rules for English Words225
Noun Endings227
Adjective Endings228
10Grammar Practice231
Note From the Author232
Introduction232
Homonyms and Other Confusing Word Pairs232
Word-Choice Pairs232
Adjective Modifiers248
Antecedents248
Collective Nouns249
Dangling Constructions and Misplaced Modifiers249
Indefinite Pronouns and Verbs249
Parallel Structure249
Personal Pronouns250
Plurals and Singulars251
Plural Pronouns with Singular Antecedents252
Sentence Structure252
Tense of Verbs253
Proper Terms for Persons253
Medical Records and Reports
11Medical Chart Notes and Progress Notes261
Note From the Author262
Introduction263
General Principles for Complete Documentation in Medical Records263
New Patient, Office264
Established Patient, Office270
Chart Note, Emergency Department Visit277
Transcription Hints277
Making Corrections284
12Preparation of a History and Physical287
Introduction288
The Formats and Styles288
The History297
The Physical Examination301
Short-Stay Record315
Interval History316
13Preparation of Miscellaneous Medical Reports321
Introduction322
Discharge Summaries322
Operative Reports326
Pathology Reports329
Radiology and Imaging Reports331
Consultation Reports335
Autopsy Protocols338
Medicolegal Reports343
Psychiatric Reports346
Correspondence and Business Documents
14Composing Business Letters and Making Travel Arrangements355
Note From the Author356
Introduction356
The Art of Letter Writing356
Writing Better Sentences356
Getting Started360
Composing360
Abstracting From Patients' Charts366
Reference Materials366
Travel Arrangements370
We Hope You Haven't Been Using These Rules!372
15Typing Reports, Memos, Minutes, and Agenda377
Introduction378
Typing Hospital Protocols and Reports378
Memoranda380
E-Mail382
Agenda384
Minutes387
Outlines388
16Applying for a Transcribing Position391
Introduction394
Prepare Your Resume395
Cover Letters400
Prospect Sources401
Electronic Job Search401
Temporary Jobs402
Prepare for the Interview402
The Interview403
Application Forms406
Professionalism407
Tips for Holding a Job407
Job Description407
Self-Employment or Freelancing408
New Business Checklist411
How to Leave a Job412
Appendices
AAnswers to Practice Tests417
BReference Materials445
Introduction445
Contents445
Abbreviations Commonly Used447
Brand-Name and Generic Drugs Most Often Prescribed454
Capitalization Rule Synopsis458
Genus and Species Names Commonly Used460
Homonyms464
Laboratory Terminology and Normal Values484
Plural Forms496
Punctuation Rule Synopsis500
Short Forms, Brief Forms, and Medical Slang502
Sound and Word Finder Table505
State Names and Other U.S. Postal Service Abbreviations512
Symbols and Numbers Rule Synopsis513
Trademarked Forms (Packaging, Dosage Forms, and Delivery Systems) Used With Drug Names514
Unusual Medical Terms Commonly Dictated in Medical Reports519
CDocuments527

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