Medical Transcription Certificate Program
Facilitator: Carrie Stein, CMT
Medical Transcription Student Instructions
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IN THE BEGINNING: Some students have difficulty getting started. The amount of reading can seem overwhelming. Communication is important, as this is quite different from being in class, even for the Facilitator.
First, on the Gatlin main medical transcription page, review the course syllabus under Resources, which goes through the Medical Transcription Certificate Program in an organized way. Here we also list a table of contents plus many other resources, including the Audio Glossary with pronunciation of medical terms, an Illustrated Atlas, a testing site, crossword puzzles, proofreading solutions, transcription templates, etc.
Second, Hillcrest Medical Center textbook: Review the extensive introduction, the information on AAMT, the model report forms, and the appendices. Keep this and your terminology textbook handy as references.
Third, thoroughly review the student information documents. Accessed on-line at your Facilitator's web site given in your welcome e-mail by your Facilitator, these documents (like the one you are reading) are designed to aid students in their course work, to learn what is involved in the medical transcription career field, and to help them with reference materials used by working medical transcriptionists. Pay special attention to the Grading Policies. The student may print the documents directly from the web site or bookmark the pages and refer to them as needed.
Grammar/Punctuation/Style Rules Review: Included in the student information documents, this review can be completed at the student's convenience, but I recommend waiting until you have transcribed all the reports in the course. The pages to study for the Grammar/Punctuation/Style Rules Review are listed on the front sheet of the student information documents.
READY TO TRANSCRIBE?
1. Install the Express Scribe digital transcriber provided to you by GES. Installation instructions are included in your materials you received from GES. Copy the voice files from the dictation CD into the Express Scribe digital transcriber. These instructions are also included in your materials.
2. Begin with Unit 1 on the Gatlin web site. Read and study all information, reading the corresponding pages in the Hillcrest Medical center text-workbook when instructed.
3. At the end of each Unit is an online computer quiz. Each quiz covers the glossary words for the corresponding inpatient case (the online quiz at the end of Unit 1 covers the glossary for Case 1, and so on). The glossary words with their definitions are listed in your textbook, and the glossary words for that inpatient case are pronounced first in the audio file for that case. Listen as they are pronounced, reading along in your textbook and/or transcribing the terms. Take the online computer quiz before transcribing any reports.
4. At the end of each unit, you will be instructed what reports to transcribe. See the Grading Policies page in the student information documents on your Facilitator's web site for a list of reports to turn in to be graded.
Cover Pages: In the textbook, the cover page for each inpatient case has the patient�s name and unique situation. In the situation paragraph, there is information about the condition that may help you in transcribing the case. You may use the cover page to record your grades for your own records. You do not have to e-mail any cover pages. There is one cover page for the Quali-Care reports. When e-mailing reports, the cover page can be used to record your grades for your own records. There is one Test Log for the Transcription Tests and the Quali-Care tests. When e-mailing reports, the Test Log can be used to record your grades yourself.
GUIDELINES FOR TRANSCRIBING REPORTS
Templates: Templates are found on the Gatlin web site under Resources|Report Forms (Templates). Templates are also found on the CD included with the Hillcrest Medical Center Beginning Transcription textbook. If you use the report templates from the CD, please complete the following steps before typing.
1. Open the template.
2. Unprotect the document (Tools>Unprotect Document) Unprotecting the document allows you to spell check and allows you to edit information in the headings at the beginning of the report..
3. Erase all gray shading from the document before typing. If you type within the gray shading, the program does not allow me to use my grading method, which is highlighting your errors.
4. Change the margins to 1 inch all the way around.
NOTE: This CD is not compatible with Vista, so if you have Vista on your computer, download the patch from the publisher's web site. The instructions for how to download the patch are on the Gatlin medical transcription web site under Resources | Student Resources. Look for the link concerning problems with studyware and follow that link. Please let me know if you have any questions concerning the patch for the studyware CD in the back of the Hillcrest textbook.
Open the desired template. Start the audio file. Enter the demographic information, i.e., Patient Name, Physician, etc., according to what you are given in your textbook and the information at the end of each MedTran Unit. Complete names of patients and doctors are given to GES students because we cannot always go by what is dictated for either patient or doctor name. If you were on the job, you would always have another way to determine this information, not having to rely on the dictated version.
After the demographic fields are complete, move into the body of the text. There is no need to tab within paragraphs.
For the left-side headings, use two spaces after each colon as long as text follows on the same line. If the heading stands alone on the line, and the text begins on the line under the heading, no colon is used. See page 24 in the Hillcrest textbook for an example.
All information should be flush left. Do not indent paragraphs.
If a list is dictated, choose either Format �bullets and numbering,� or manually type the numbers at the left margin one under the other.
Refer to pages 51 and 52 of Hillcrest, "Report Formatting Guidelines," for help.
If your document requires a second page, double space and type (Continued) as the last line of text on page one. Begin page two with the type of report. Next enter the patient�s name, hospital number, the appropriate date, and page 2. The same format should be used if you need a third page. After the demographic information, leave three blank lines, then continue with your report on the fourth line. See below.
-----------------------------------------------------TOP OF PAGE----------------------------------------------------
HISTORY AND PHYSICAL EXAMINATION
Patient Name: Jane Doe
Hospital No.: 123456
Admission Date: 00/00/----
Page 2
Start typing the body of your report here . . .
For the signature line, drop four lines from the last line of text. Underline 25 spaces on which the doctor is to sign his/her name. Directly under that, type the doctor�s full name and title. A nickname may be dictated or even used as a written signature, like LD for Larry D.; however, the full name and title is typed underneath the signature line.
EXAMPLE -- Last line of text
_________________________
Larry D. Lawson, MD, PhD
*WARNING* If the signature line tries to autoformat into a line across the page, simply backspace once, and the line will go back to 25 spaces.
For the sign-off block, leave one blank line under the signature block.
Type the doctor's initials, a colon, and the transcriptionist's initials.
Under that line type the date dictated then, on the line under that, type the date transcribed.
This is all typed close together, a little block of information, as follows.
LDL:cp
D:00/00/----
T:00/00/----
Remember, the date dictated MUST correlate with the date of admission for H&P
reports, the date of surgery for OP Notes, the date of discharge for discharge
summaries, the date the film was taken for radiology reports, and the date received/date
reported for pathology reports.
If a copy or copies are to be sent out, leave one blank line under the sign-off block, and
type as follows. You can use C, CC, c, or cc, but be consistent throughout your work.
C: Lauren Rae, MD
Travis David, DO
Sheila Green, RN
TRANSCRIBING STEPS
First, using the above guidelines, transcribe the report, proof it against the solutions on the Gatlin web site, mark the errors, and research the errors so you know what you did wrong and why. Researching the errors can be done using your medical dictionary provided by Gatlin, your abbreviation book supplied by Gatlin, the English grammar and punctuation guide, also provided by Gatlin, and/or an English dictionary. Please note that your reports do not have to have page breaks in exactly the same place as the solutions and your lines of text do not have to be the same length as in the solutions. Your font might be smaller or larger than the font used in the solutions. You should follow the written formatting guidelines on pages 51 and 52 in the the Hillcrest Beginning Medical Transcription textbook. The Model Report Forms, pages 16 through 38 in the Hillcrest textook, show examples of the written formatting guidelines.
Second, go back to the audiofiles and retranscribe the report using your research notes to help you with mistakes you made the first time.
Third, repeat these steps as many times as necessary to come up with a final draft as perfect as you can make it. THAT is what to e-mail to your Facilitator for grading. Do the above steps even with the tests and with the work you do not send. Repeating each dictation, learning the glossary words, and listening for the subtleties in dictation are all good ways to learn.
If you have questions about the above instructions or finding what you need in your textbook or student information documents, let your facilitator know. Help is available!
Quali-Care: Note the patient name and short descriptive paragraph before each Quali-Care outpatient glossary. This gives information about both the patient and the actual report. Some Quali-Care reports use an HPIP format, some a SOAP format, and some use a plain format. For example, QC report 1 is a CT scan, and this is simply transcribed in plain format on a blank document.
Model Report Forms in the textbook (pages 16 through 38) show how reports are formatted and styled at Hillcrest. This style is not written in stone. (See page 40, "Style Variations," in Hillcrest) In the working world, each employer or client will have their own format/style preferences. If, perchance, someone expects you to use your style, you will have something to go by. Consistency in your work is most important, regardless of the style used.
Sign-off block: On the Model Report Forms, please note the �sign-off block� or �signature block� at the end of each report, to include (1) the dictator�s initials, (2) transcriptionist�s initials, (3) date dictated, and (4) date transcribed. (Note: The initials are traditionally typed in the style seen below; however, some may prefer both sets of initial in caps, others all in lowercase. You will use the syle your employer/client prefers.) As you are working your way through the ten inpatient cases, the 25 outpatient reports, and the transcription tests, remember this: The date transcribed must be within one or two days of the date of dictation.
For example, if the date of a procedure or examination is 8/5/----, then the report was probably dictated that day. A procedure or exam dictated on 8/5/---- was probably transcribed that day or soon thereafter. You will not use your actual date of transcription in this course. Also, transcribing the year is not done in this course. Four dashes work fine. Why four? Because a 4-digit year is the new standard. Type the sign-off block two lines below the signature line, flush left, as follows. (See page 51, #13 in Hillcrest.) Note:. No spaces are used in the sign-off block.
SAG:cs
D:10/26/----
T:10/28/----
For pathology reports the gross (or macroscopic) description is dictated the date the specimen was received. The microscopic diagnosis is dictated on the date reported. This means there are two sign-off blocks per pathology report. (Dates received and reported are found in the heading information.) The dates of transcription will conform to this plan for the purposes of this course. In real life, the D/T dates may be different depending on factors over which the MT has no control. There may be two different transcriptionists who transcribe the pathology report; one transcriptionist may transcribe the gross description or macroscopic description, then on the next day another transcriptionist may transcribe the microscopic description and diagnosis. (See "Pathology Report" on page 13 in Hillcrest.)
Spellcheck use is expected, and having a medical spellcheck is a definite advantage, even though it does not take the place of proofreading your work. In a Word 2003 (and prior versions) document, before you begin transcribing, go to Tools, then Options, click on the Spelling & Grammar tab, and take out the check mark where it says to ignore words in all caps. You definitely want to spellcheck words that are in all caps. If you have Word 2007, look in Help under "ignore words in uppercase" to find the commands.
More than one page? When a report has two or more pages, at least two lines of type should be brought over to the next page. This does not include page-two heading information or signature line with sign-off block. Two or more lines of the actual report must be brought over to the next page. (See page 51, #8 in Hillcrest.)
Copies? If a copy is to be sent, that information goes two lines below the sign-off block. (See page 51, #14 in Hillcrest.) It can be shown as either C (copy) or CC (courtesy copy) followed by a colon. Either upper case or lower case letters are equally correct here. Tab over for the name of the person to receive the copy. If more than one person is to receive a copy, line up the names. See the example below.
CKS:sag
D:11/16/----
T:11/17/----
C: John Wayne, MD
Harrison Ford, PhD
Julia Roberts, DO
NOTE: If there are contradictions in the transcription solutions as compared to the dictation, it is the student�s responsibility to bring this to the attention of their Facilitator and get an answer before sending their work for grading. Close communication with your Facilitator is an important part of each student�s success in this program. Never hesitate to bring something to your Facilitator�s attention�she is waiting to hear from you.
REMEMBER: Medical transcriptionsts are word people, detail-oriented, self-starters. We can concentrate heavily for long periods of time. We are focal people (not easily distracted) rather than peripheral people.
Welcome to the land of the picky people: Medical Transcription.