Medcal Terminology/Transcription On-Line Course
Facilitator: Carrie Stein, CMT
On-line Medical Transcription Student Information
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Getting Started With Your On-Line Learning Experience: In my experience as a GES Facilitator, I find some students have difficulty getting started. It is so different from being in class, even for the Facilitator! Here is my suggestion for the order in which to read your material.
First, thoroughly review the student information documents. Accessed on-line at your Facilitator's web site given in your initial e-mail from Gatlin Education Services and by your Facilitator, these documents are for students to read, study, and keep for future reference. The student may print the documents directly from the web site or bookmark the page and refer to it as needed. Grammar/Punctuation/Style Rules Review: Included in the student information documents, this review can be completed at the student�s convenience. (Grade is included in your final average.)
Second, review the Gatlin Education Medical Transcription web site. Here is offered a pronunciation of medical terms, a review of anatomy, a testing site, solutions to the transcribed reports, word games, proofreading exercises, medical terminology course, and transcription templates. Click on each icon and read through the information.
Third, complete the medical terminology module to give you a foundation in medical language. The module is designed to be studied with the Medical Terminology Made Easy textbook and the medical terminology icon on the web site.
Fourth, read your Hillcrest Medical Transcription text-workbook, including the Preface, pages 3-8, 13-15, 41-49, and 216-221. Review the information on how Hillcrest Medical Center is set up, how to transcribe at Hillcrest, English grammar and punctuation tips, medical language tips, difficult and sound-alike terms, information on AAMT, and model report forms prior to starting your transcription. Keep it handy afterward as a reference.
Finally, go to the Navigation Menu on the web site. Start with Unit 1 (out of 20). At the end of each unit, you will be prompted to transcribe a case from your text-workbook by using your transcribing equipment. You may also be prompted to take a written quiz. These are on-line quizzes that are found in the testing area and are set up as open-book quizzes to be done as you go through the web site.
Ready to transcribe? Before each case is dictated, the entire glossary for that case is pronounced. Listen to the terms, reading along in your textbook and/or transcribing the terms as they are dictated. Learn these words--don�t make a mistake on a term that is in the glossary!
In the textbook, the cover page for each 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. In the middle of this page, you will see a line for Student Name, underneath which is a listing for the date completed and a grade for each of the reports in that case. When mailing the case in for grading, please include this cover page with your full name, mailing address, and each report�s completion date. After marking your work, I�ll return it to the address given, cover page attached, with grades filled in. If you are e-mailing your work as an attachment, you may use the cover page to record your grades for your own records.
Quali-Care: The one cover page for the Quali-Care outpatient reports (page 154) is intended to be copied. Please put your name and address on the page before copying and sending reports for grading. If you are e-mailing reports, again, the cover page can be used to record your grades for your own records. Note the patient name and short descriptive paragraph before each Quali-Care outpatient glossary. This gives information about both the patient and the report. Some Quali-Care reports use HPIP, some SOAP, and some use just a plain format. For example, QC report 1, a CT scan, uses a plain format. (That means you can transcribe it on a plain piece of paper.)
Model report forms on the Hillcrest diskette and in the textbook on pages 19-37 show how reports are formatted and styled at Hillcrest. This style is not written in stone. When you go out into the working world, each employer or client will have their own format/style. If, perchance, someone asks you to use your format/style, at least you will have learned something to use. Consistency in your work is most important, regardless of the style used.
Transcribing Steps
First, 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. Your font might be smaller or larger than the font used in the solutions. You should follow the formatting guidelines on the Model Report Forms, pages 19 through 37 in the Hillcrest Beginning Medical Transcription text-workbook, and the formatting guidelines on pages 50 and 51 in the the Hillcrest textbook.
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 or 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.
Keep in close touch with your Facilitator. She can help, can answer questions, can solve problems, can keep you on track, and can offer tips on getting a job--but only if you involve her in your experience.
Sign-off block: On the Model Report Forms, please note the �sign-off block� or �signature block� at the end of each report. This includes the dictator�s initials, transcriptionist�s initials, the date dictated, and finally the date transcribed. As you are working your way through the ten inpatient cases, the 20 outpatient reports, and the 15 transcription tests, remember that the date transcribed must closely follow the date of dictation. For example, if a procedure/exam was performed on 8/5/----, it would probably be dictated on 8/5---- and transcribed that day or soon thereafter. You will not use your actual date of transcription in this course because the date that you transcribe the report may not correspond closely enough to the dictation date given. Also, for the purposes of this course, always use four dashes for the year in all reports, including year of birth on the outpatient reports. Why four dashes? Because a 4-digit year is the new standard. Transcribe the sign-off block two lines below the signature line, flush left, as follows.
GES:cks
D:8/5/----
T:8/6/----
For pathology reports, the gross description (or macroscopic description) is dictated the date the specimen was received. The microscopic description is dictated on the date reported. This means there are two sign-off blocks per pathology report. (You will find the dates received/reported in the heading information.) The date of transcription will conform to this for the purposes of this course. In real life, the D/T dates may be different depending on many factors over which the MT has no control. There may be two different transcriptionist 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.
More than one page? When a report has two or more pages, remember at least two, preferably three lines of type, should be brought over to the next page. This does not include page-two heading information. Two or more lines of the actual report must be brought over.
Copies? If a copy is to be sent out, that information goes two lines below the sign-off block. You can type either c (copy) or cc (courtesy copy), then a colon followed by two spaces, then the name of the person(s) who will receive a copy of the report. If more than one person is to receive a copy, line up the names. Make it look nice, neat, professional, and flush left, as follows.
CKS:ges
D:10/26/----
T:10/28/----
c: John Wayne, M.D.
Harrison Ford, Ph.D.
Julia Roberts, D.O.
Difficulty with diskette? Some of the template diskettes do not allow double spacing or indenting. You can get around that problem by unprotecting the template in MS Word. To do this, click on the Tools menu, choose Unprotect Document, and that's all there is to it. If you prefer, however, just bring each line back to the left margin. We are primarily learning how to transcribe medical dictation�turning the spoken word into the written word�and formatting is secondary at this point. There are many correct ways to format reports. (Report formats are also offered on the GES web site.)
Voice recognition technology is briefly addressed near the end of page 54 of your Hillcrest textbook. This is the future of transcription. It will be exciting to be medical editors in addition to being transcriptionists. This is not something to fear, but something to embrace.
Subscript/Superscript: If you want a subscript, like with S1, S2, using Microsoft Word you would highlight the 1. Press CTRL plus �=� and this will make the 1 a subscript (sub = below). Highlight the 2, repeat the steps, and you wind up with S1, S2. If you put this phrase in a macro or in AutoText and name it �S,� your work can look professional and you will transcribe only one letter. (Heart exam: Normal S1, S2.)
To create a superscript, highlight the number and press CTRL plus the plus sign. This will create a superscript. Phrases like PCO2 and mg/m2 can use subscripts/superscripts but are okay with the numbers typed on the line.
Symbols/Special Characters: These are found by going to Insert, then to Symbol. At that point you have both symbols and special characters. Pick the one you need, click on insert, and the symbol/character pops up right in your line of type.
Examples: � for copyright � for trademark for paragraph � for a bullet point
AutoText: Under Insert, you also find AutoText. To save a phrase in AutoText, just highlight the phrase, go to Insert, then to AutoText, then to New. Here you name your entry and click on OK.
If you ever want to change the entry, go through the same steps. The computer will ask if you want to change the existing entry, and you click on yes to change. Click on no to keep it the same.
To see a list of your AutoText entries, click on Insert, then AutoText, then AutoText again.
AutoCorrect: A feature under Tools, this is what makes Microsoft Word automatically correct as you type. Look at the list of mistakenly typed words with the correct words next to them. You can add to this list. I often transcribe �pateint� instead of patient. So, in my AutoCorrect, I added that to the list of misspelled words. Now every time I type �pateint,� it is automatically changed to patient.
This is not an endorsement for Microsoft Word, just an explanation of how to make use of some of the features to maximize your production level.
By the way, for those students who have completed their course work, GES can offer postgraduate dictation to help in refining your skills. Please let your Facilitator know if this work is something that would interest you.
NOTE: If the equipment and/or CDs used in the GES Medical Transcription program prove to be defective, please let Candice at GES know immediately. Defective equipment will be replaced as soon as possible.
Phone: 817-870-2870 office
Fax 817-870-2871
E-mail [email protected]