MR270 Medical Transcription MR270 Medical Transcription III III

Unit 3Unit 3

Dictation Errors and GastroDictation Errors and Gastro

Lisa Kay LashleyLisa Kay Lashley

Dictation ReviewDictation Review

Common ErrorsCommon Errors SpellingSpelling ProofreadingProofreading AbbreviationsAbbreviations

We tend to just type what we We tend to just type what we hear without really hear without really comprehending what we are comprehending what we are typing. This is why we typing. This is why we proofreadproofread. .

Does it make sense?Does it make sense?

Atopic or ectopic?Atopic or ectopic? Occasional ventricular______beats Occasional ventricular______beats

noted?noted?

Atopic: Atopic: relating to, or caused by a hereditary predisposition toward developing certain hypersensitivity reactions, such as hay fever, asthma, or chronic urticaria…

Ectopic: heartbeats that are small variations in an otherwise normal heartbeat that

Does it make sense?Does it make sense?

Adrenal vs. RenalAdrenal vs. Renal Would you use adrenal in reference Would you use adrenal in reference

to cardiology?to cardiology? Mild Mild adrenal/renaladrenal/renal artery disease? artery disease?

Vessel vs. muscleVessel vs. muscle Plaquing of the right superficial Plaquing of the right superficial

femoral artery with distal femoral artery with distal muscle/vesselmuscle/vessel disease? disease?

Does it make sense?Does it make sense?

Thumb popliteal vs Thumb popliteal vs femoropoplitealfemoropopliteal Catheterization reportCatheterization report

Exam suggesting left Exam suggesting left thumb thumb popliteal/femoropopitealpopliteal/femoropopiteal disease? disease?

Febrile vs. FibrillationFebrile vs. Fibrillation Dr. XXXX, electrophysiologist, with Dr. XXXX, electrophysiologist, with

DC DC febrile/fibrillation febrile/fibrillation inductions?inductions?

AbbreviationsAbbreviations

It is a good idea to spell out most It is a good idea to spell out most abbreviations (except for laboratory, abbreviations (except for laboratory, diagnostic, and radiology and metric diagnostic, and radiology and metric units of measure).units of measure).

Hospitals will have a list of Hospitals will have a list of abbreviations that can be used. Clinics abbreviations that can be used. Clinics use abbreviations a little more use abbreviations a little more liberally. liberally. See doc sharing for more See doc sharing for more

information on abbreviations and information on abbreviations and what is acceptable or not.what is acceptable or not.

Dictation ContDictation Cont

Abbreviations: Abbreviations: All or nothingAll or nothing.. Stay consistentStay consistent- Don’t start dictation using - Don’t start dictation using

abbreviations then switch to spelling out the abbreviations then switch to spelling out the acronyms later in the dictation.acronyms later in the dictation.

If you spell out one acronym (ex. PVC, then spell If you spell out one acronym (ex. PVC, then spell out all acronyms) except for medications.out all acronyms) except for medications.

Lab-if you use abbreviations (acronyms) for one Lab-if you use abbreviations (acronyms) for one use it for all. (i.e. BP 102/63, HR 85 etc…) NOT use it for all. (i.e. BP 102/63, HR 85 etc…) NOT ( Blood pressure 102/63, HR 85) stay consistent. ( Blood pressure 102/63, HR 85) stay consistent.

If you put cath lab in one section of dictation put it If you put cath lab in one section of dictation put it throughout, don’t switch to catherization laboratory throughout, don’t switch to catherization laboratory (stay consistent). (Preferred way, if they say cath (stay consistent). (Preferred way, if they say cath lab they expect you to type out catherterization lab they expect you to type out catherterization laboratory. I have not been marking off for this; laboratory. I have not been marking off for this; many did it. many did it.

Dictation Cont.Dictation Cont.

PROOFREAD—make sure what you are typing PROOFREAD—make sure what you are typing makes sense with what you are discussing. Don’t makes sense with what you are discussing. Don’t put it in there because that is what it sounds like. put it in there because that is what it sounds like. 5-Fringe sheet (supposed to be 5-French 5-Fringe sheet (supposed to be 5-French

sheath) many of you did this. Does it make sheath) many of you did this. Does it make sense? Is there such a thing, and is it related sense? Is there such a thing, and is it related to what you are typing?to what you are typing?

Preoperative/Postoperative: It is a great Preoperative/Postoperative: It is a great feature that you can copy and paste one to feature that you can copy and paste one to the other when the doctors says same; the other when the doctors says same; however, if it is however, if it is wrongwrong in the one you copied in the one you copied from it will be from it will be wrongwrong in the paste as well, SO in the paste as well, SO PROOFREAD…..PROOFREAD…..

Unit 1 and 2 Overview Unit 1 and 2 Overview (Cont.)(Cont.)

Flagged dictation. It is okay to Flagged dictation. It is okay to flag dictation when all other flag dictation when all other resources have been utilized. resources have been utilized.

Wrong words—Again does it Wrong words—Again does it make sense?make sense?

Grammar– ‘s, ly, ed –many of Grammar– ‘s, ly, ed –many of you missed the grammar in your you missed the grammar in your dictations. dictations.

Dictation ConclusionDictation Conclusion

What we hear and what we type What we hear and what we type may not be the same. Just may not be the same. Just because it sounds right doesn’t because it sounds right doesn’t mean it is. Does it makes sense mean it is. Does it makes sense within the scope of what you are within the scope of what you are transcribing? If you are typing transcribing? If you are typing Cardiology are the words you are Cardiology are the words you are using go to cardiology? Or using go to cardiology? Or orthopedics? Or whatever it is you orthopedics? Or whatever it is you are transcribing?are transcribing?

Week 3 SeminarWeek 3 Seminar

This week in MT Client you are doing This week in MT Client you are doing operative reports in relation to Gastro operative reports in relation to Gastro and Orthopedics. We did orthopedics in and Orthopedics. We did orthopedics in unit 2, this week we will discuss gastro.unit 2, this week we will discuss gastro.

We will reserve questions to the end of We will reserve questions to the end of the seminar.the seminar.

Be kind and stay positive---no Be kind and stay positive---no negativity please. negativity please.

I will be assigning questions this week I will be assigning questions this week so listen for your name; please let so listen for your name; please let those people answer. those people answer.

Is Everyone Ready?Is Everyone Ready?

GI DisordersGI Disorders

Define the disorders belowDefine the disorders below

1.1. Gastroesophageal Reflux Gastroesophageal Reflux DiseaseDisease

2.2. Hiatal HerniaHiatal Hernia

3.3. Peptic UlcerPeptic Ulcer

4.4. PeritonitisPeritonitis

5.5. Crohn’s DiseaseCrohn’s Disease

SpellingSpelling

Correct the spelling if necessaryCorrect the spelling if necessary

1.1. EsophagastroduodenoscopEsophagastroduodenoscopyy

2.2. ProctosigmoidoscopyProctosigmoidoscopy

3.3. LaperroscopyLaperroscopy

4.4. PeritonoscopyPeritonoscopy

5.5. Serum amylazeSerum amylaze

AbbreviationsAbbreviations

1.1. ERCPERCP

2.2. GE junctionGE junction

3.3. GGTGGT

4.4. HALHAL

5.5. PEG tubePEG tube

6.6. TPNTPN

MedicationsMedications

What are the generic names What are the generic names for the medications below?for the medications below?

1.1. PrilosecPrilosec

2.2. ZantacZantac

3.3. BentylBentyl

Multiple ChoiceMultiple Choice

1.1. Coughing or spitting up of blood Coughing or spitting up of blood from the respiratory tract:from the respiratory tract:

1.1. HematocheziaHematochezia

2.2. HemoptysisHemoptysis

2.2. The passage of bloody stools:The passage of bloody stools:1.1. HematocheziaHematochezia

2.2. hemoptysishemoptysis

Multiple ChoiceMultiple Choice

1.1. PancreaticoduodenectomyPancreaticoduodenectomy1.1. Whipple procedureWhipple procedure

2.2. Barron ligationBarron ligation

2.2. Blood ChemistryBlood Chemistry1.1. D-XyloseD-Xylose

2.2. Serum lipaseSerum lipase

Define the Terms Define the Terms Below…Below…

FibromyalgiaFibromyalgia HypercholesterolemiaHypercholesterolemia crepituscrepitus Prothrombin time (PT)Prothrombin time (PT) Prostate-specific antigen (PSA)Prostate-specific antigen (PSA) Thrombin time (TT)Thrombin time (TT)

IM things you’ll IM things you’ll encounterencounter

List a test, medication, and List a test, medication, and abbreviation that you will abbreviation that you will encounter when transcribing encounter when transcribing dictation in one of the diseases dictation in one of the diseases associated with this specialty. associated with this specialty. See the example below:See the example below: Hypertension: a blood pressure Hypertension: a blood pressure

greater than 140/90 mm Hg on greater than 140/90 mm Hg on three occasions separated by at three occasions separated by at least 1 month, vasodilators, BP.least 1 month, vasodilators, BP.

Good Night All….Good Night All….

•Thanks for another great Seminar.•Hope you learned something.•Don’t forget to keep up with all of your transcription!•See you the same time—same place next week!