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

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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.
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Product Details

  • ISBN-13: 9780721695686
  • Publisher: Elsevier Health Sciences
  • Publication date: 10/2/2002
  • Edition description: Older Edition
  • Edition number: 5
  • Pages: 608
  • Product dimensions: 8.52 (w) x 10.94 (h) x 1.03 (d)

Table of Contents

Career Role and Responsibilities
1 The Medical Transcriptionist's Career, Including Ethical and Legal Responsibilities 3
Note From the Author 4
Introduction 4
Medical Communication 4
Job Opportunities 4
Job Descriptions 5
Transcription Skills 8
Medical Records 8
Transcription Speed 8
Physically Challenged Transcriptionists 9
Certification for Medical Transcriptionists 9
Ethical and Legal Responsibilities 10
Confidentiality 14
Transcriptionist's Notebook or File 22
Tools of Transcription
2 Equipment and Technology 27
Note From the Author 28
History 28
Computer Systems 30
Ergonomics 33
Dictation Equipment 33
Hand/Foot Control 36
Dictation 37
Maintenance 38
Transcription Preparation 39
Equipment for the Physically Challenged 40
Facsimile Machines 41
Vocabulary 42
Transcription Guidelines
3 Punctuation 47
Note From the Author 48
Introduction 48
Vocabulary 48
The Comma 55
The Period and Decimal 68
The Semicolon 68
The Colon 69
The Hyphen 72
The Dash 75
The Apostrophe 75
Quotation Marks 78
Parentheses 79
The Slash (Also Called the Bar or Diagonal) 80
Spacing 80
Punctuation Rule Synopsis 86
4 Capitalization 93
Introduction 94
Vocabulary 94
Rules 94
Capitalization Rule Synopsis 105
5 Transcribing Numbers, Figures, and Abbreviations 109
Introduction 110
Typing Numbers 110
Use of Symbols 121
Use of Abbreviations, Acronyms, Initialisms, and Brief Forms 122
Abbreviation Reference 126
Postscript 130
Symbol and Number Rule Synopsis 130
6 Letter Transcription 135
Note From the Author 136
Introduction 136
Vocabulary 136
Letter Formats 137
Qualities of a Mailable Letter 142
Two-Page Letters 151
Copies 151
File Notation 151
Placement 152
Paragraphing 153
Envelope Preparation 157
7 Making Proofreading Corrections, and Quality Assurance 163
Note From the Author 164
Introduction 164
Where Errors Occur 164
Accuracy 165
Types of Errors 165
Editing 169
Flagging 172
How to Proofread 176
Proofreader's Marks 179
8 Using Reference Books: Learn How to Get Help From the Experts 191
Note From the Author 192
Introduction 192
The English Dictionary 192
The Medical Dictionary 193
Medical Word Books 197
Using Reference Books 197
Software Spell Checker 202
Compound Words 203
French Medical Words 205
Spelling the Names of Drugs 206
Web Sites 211
Laboratory Terminology and Normal Values 214
9 Word Endings: Plurals, Nouns, and Adjectives 219
Introduction 220
Vocabulary 220
Plural Endings 220
Forming Plurals of Medical Terms 220
Basic Plural Rules for English Words 225
Noun Endings 227
Adjective Endings 228
10 Grammar Practice 231
Note From the Author 232
Introduction 232
Homonyms and Other Confusing Word Pairs 232
Word-Choice Pairs 232
Adjective Modifiers 248
Antecedents 248
Collective Nouns 249
Dangling Constructions and Misplaced Modifiers 249
Indefinite Pronouns and Verbs 249
Parallel Structure 249
Personal Pronouns 250
Plurals and Singulars 251
Plural Pronouns with Singular Antecedents 252
Sentence Structure 252
Tense of Verbs 253
Proper Terms for Persons 253
Medical Records and Reports
11 Medical Chart Notes and Progress Notes 261
Note From the Author 262
Introduction 263
General Principles for Complete Documentation in Medical Records 263
New Patient, Office 264
Established Patient, Office 270
Chart Note, Emergency Department Visit 277
Transcription Hints 277
Making Corrections 284
12 Preparation of a History and Physical 287
Introduction 288
The Formats and Styles 288
The History 297
The Physical Examination 301
Short-Stay Record 315
Interval History 316
13 Preparation of Miscellaneous Medical Reports 321
Introduction 322
Discharge Summaries 322
Operative Reports 326
Pathology Reports 329
Radiology and Imaging Reports 331
Consultation Reports 335
Autopsy Protocols 338
Medicolegal Reports 343
Psychiatric Reports 346
Correspondence and Business Documents
14 Composing Business Letters and Making Travel Arrangements 355
Note From the Author 356
Introduction 356
The Art of Letter Writing 356
Writing Better Sentences 356
Getting Started 360
Composing 360
Abstracting From Patients' Charts 366
Reference Materials 366
Travel Arrangements 370
We Hope You Haven't Been Using These Rules! 372
15 Typing Reports, Memos, Minutes, and Agenda 377
Introduction 378
Typing Hospital Protocols and Reports 378
Memoranda 380
E-Mail 382
Agenda 384
Minutes 387
Outlines 388
16 Applying for a Transcribing Position 391
Introduction 394
Prepare Your Resume 395
Cover Letters 400
Prospect Sources 401
Electronic Job Search 401
Temporary Jobs 402
Prepare for the Interview 402
The Interview 403
Application Forms 406
Professionalism 407
Tips for Holding a Job 407
Job Description 407
Self-Employment or Freelancing 408
New Business Checklist 411
How to Leave a Job 412
Appendices
A Answers to Practice Tests 417
B Reference Materials 445
Introduction 445
Contents 445
Abbreviations Commonly Used 447
Brand-Name and Generic Drugs Most Often Prescribed 454
Capitalization Rule Synopsis 458
Genus and Species Names Commonly Used 460
Homonyms 464
Laboratory Terminology and Normal Values 484
Plural Forms 496
Punctuation Rule Synopsis 500
Short Forms, Brief Forms, and Medical Slang 502
Sound and Word Finder Table 505
State Names and Other U.S. Postal Service Abbreviations 512
Symbols and Numbers Rule Synopsis 513
Trademarked Forms (Packaging, Dosage Forms, and Delivery Systems) Used With Drug Names 514
Unusual Medical Terms Commonly Dictated in Medical Reports 519
C Documents 527
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