Medical Terminology/Transcription On-Line Course
Facilitator: Carrie Stein, CMT
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VITAL SIGNS, SUTURE SIZING, SHARP AND BLUNT DISSECTION, OBSTETRICAL TERMINOLOGY
In the following list of eight doctors� dictated vital signs, you will note different sequences and different criteria, even though these doctors practice in the same clinic setting. The doctors always dictate their patients' vital signs in the same sequence, sometimes dictating numbers only with no words.
1. Blood pressure, pulse, respirations, temperature Doctor's initials
BP 120/80, P 79, R 22, T 98 SCC
2. Temperature, pulse, blood pressure
T 99, P 82, BP 156/90 DHG
3. Blood pressure, pulse, temperature, weight
BP 90/70, P 65, T 100.1, weight 102-1/2 pounds REB
4. Temperature, pulse, blood pressure, weight TDF
T 95.5, P 82, BP 140/75, weight 190-3/4 pounds
5. Weight, blood pressure, temperature, pulse JAL
Weight 264 lb., BP 200/100, T 99.6, P 102
6. Blood pressure, temperature, pulse, respirations JEM
BP 132/78, T 97.5, P 72, R 20
7. Temperature, blood pressure, weight, height STW
T 98.7, BP 145/69, weight 156 pounds, height 63 inches
8. Blood pressure alone. JDMc
BP 179/83
Doctors begin dictating early in their training and might copy a mentor, a fellow student, or just do what comes naturally. No one teaches doctors exactly how to dictate their records. It is the medical transcriptionists' job to transcribe each doctor�s dictation correctly and in the doctor's specific style.
In the above examples, the transcriptionist should not make the styles the same, not add information that was not dictated. If the dictation is cut off or unclear, leave a blank and/or flag the report for the originator. If you have access to the medical record, however, you may look up the vitals and include the correct information. Make sure you check the date of visit and the date of dictation to get the correct numbers.
SUTURE SIZING
The Brown & Sharp (B&S) gauge uses whole numbers, ranging from 40 to 20 (smallest to largest), making a size 35 suture smaller than a size 25 suture.
The USP system sizes steel, silk, cotton, and other materials ranging from 11-0 to 7 (smallest to largest). This makes a size 7 suture different from and larger than a size 7-0. Remember, this is a zero, dictated as "seven oh." Use either 0 or 1-0 cotton, 00 or 2-0 silk, 000 or 3-0 Vicryl; however, for >000, use the "digit-zero" style. The many brand names of suture materials will have an initial capital letter (initial cap), and generic names will be in all lower case.
SHARP AND BLUNT DISSECTION
Sharp and blunt dissection: This phrase takes a singular verb. The idea is that the surgeon is separating tissues by a process alternately involving sharp use of instruments (snipping with scissors or cutting with a scalpel) and blunt use (inserting scissors or clamp with blades closed, then opening them to establish a plane of separation; or using a finger, a sponge, or an instrument to develop a separation already started). Hence the whole process is just one dissection, but it involves two different types of activity. A singular verb is appropriate.
OBSTETRICAL TERMINOLOGY
Obstetrical terminology: (gravida and para )
There are several ways to correctly write the phrase containing �gravida� and �para.� If a woman has had 3 pregnancies, 2 full-term deliveries, 1 miscarriage, and has 2 living children, this can be written:
a. gravida 3, para 2, ab 1 OR
b. gravida 3, para 2, abortus 1 OR
c. gravida 3, para 2, a 1 OR
d. G3, P2, A1 OR
e. gravida 3, para 2-0-1-2 (3 pregnancies, 2 full-term deliveries, 0 premature deliveries, 1 miscarriage, and 2 living children)
Use the style dictated by the originator of the report. The words gravida and para are not capitalized except at the beginning of a sentence, and arabic numerals are used.
In order to �add up� the numbers and make sure they are correct, if using style �a,� �b,� �c,� or �d� above, add the number of deliveries and abortions or miscarriages. That number should equal the number of pregnancies.
For style �e� above, add the number of full-term deliveries, premature deliveries, and abortions or miscarriages. That number should equal the number of pregnancies.
If the numbers do not �add up,� check the medical record if you have access to it, contact the originator of the report, or flag the report to let the originator know that there is a discrepancy in the numbers.