FOCUS AND GOALS
This course has been brought together from books and material based on an extensive anatomy and physiology study to familiarize the student with the body systems, broken down into twelve groupings, and five specialty categories; as well as the understanding of the basic word forms which make up a great part of the medical vocabulary; and a complete analysis of what is involved in medical report processing; including punctuation, capitalization, formatting, usage, grammar, ethics, accuracy, and knowledge of the various aspects of these functions as they apply to the transcription of medical reports. Reference materials, work environments, technology, editing, proofing, employment issues, and the health care record with a detailed description of what is included in each basic type of medical report and how they are transcribed, are also an integral part of what is emphasized. At the end of each unit, sections will be introduced and discussed from the BOOK OF STYLE, published by the Association for Healthcare Documentation Integrity (AHDI).
Throughout the course, viewpoints from physicians and medical professionals, including transcriptionists, will be brought to the attention of the student, through articles and guest speakers. The proofing and typing of actual physician dictation will be an integral part of the assignment requirement, as well as a “review†for each unit; assignments which require internet research, skill and familiarization drills, and some fun exercises.
Notes
NOTE: The following sources and resources were utilized in putting together the information below:
* The Association FOR Healthcare Documentation Integrity (AHDI) curriculum and guidelines for selecting text and reference material;
* Medical Transcription, Fundamentals and Practice, by Linda Campbell, et al;
* Delmars Comprehensive Medical Terminology, by Bette Davis Jones;
* The Medline-Plus medical encyclopedia on line, sponsored by the National Institutes of Health;
* The complete set of medical, pharmacological and specialty reference guides, published by Stedman;
* The Book of Style, published by the AHDI;
* 120+ hours of physician dictation.
INTRODUCTION: An Overview of Medical Transcription in General, and to This Course in Particular
A. What is MEDTRANSCLASS.COM?
B. What is the Agenda for This Course?
C. Why a Completely Oral Class?
D. Recording and Transcribing
E. Assignments, Reviews and Medical Reports
F. General Information About Those Who Dictate
G. Expectations of a Medical Transcriptionist; and of MEDTRANSCLASS Students
UNIT 1: FUNDAMENTALS OF MEDICAL TRANSCRIPTION
A. Careers
B. Technology
C. Editing and Proofreading
D. Reference Material
E. Medicolegal Considerations Such as the HIPAA
F. The Correction of Transcripts, etc.
G. Information About Medical Records and the Role They Play
H. An In-depth Look at Formatting and Style in Regard to Specific Medical Report Transcription
UNIT 2: WORD-BUILDING
A. Word Structure
1. combining forms
2. prefixes and suffixes
3. plurals and noun and adjective endings
B. Whole-Body Terminology
1. Structural organization
2. regions/quadrants, cavities
3. Directional terms
C. Style Section: OTHER WORD ASSOCIATIONS
1. Homonyms and eponyms
2. Confusing words
3. Words to avoid
4. Medical slang
5. Brief forms
6. Miscellaneous
UNIT 3: PHARMACOLOGY
A. Drug Laws and Standards
B. Actions and Interactions
C. Classifications
D. Routes of Administration of Medications
E. Medication Abbreviations
F. Medication Categories and Examples
G. Medication Vocabulary
H. Dangerous Abbreviations
I. Style Section:
1. General abbreviations not linked to pharmacology
2. acronyms
UNIT 4: INTEGUMENTARY SYSTEM/DERMATOLOGY
A. Overview of the System –Anatomy and Physiology
B. Vocabulary
C. Abbreviations
D. Combining forms
E. Diagnostic Procedures/Laboratory Terms
F. Pathological Conditions
G. Pharmacology
H. Transcription tips
I. Style Section: Capitalization
UNIT 5: THE MUSCULOSKELETAL SYSTEM:
BONES/MUSCLES/JOINTS/ORTHOPEDICS
A. Overview of the unit –Anatomy and Physiology
B. Description of Bones, Muscles, Joints, Cartilage, Tendons and Ligaments
C. Vocabulary
D. Abbreviations
E. Combining Forms
F. Specific Bones of the Head and Face, Upper and Lower Extremities and Trunk of the Body
G. Specific Muscles as Above
H. Joints, Main Types and Subclassifications
I. Tendons and Ligaments
J. Types of Movements
K. Diagnostic Procedures
1. Laboratory Studies
2. Tests/Signs Which Require Active/Passive Motion
3. Invasive procedures
L. Pathological Conditions
M. Pharmacology
N. Transcription Tips
O. Style section: accent marks, ampersand, braces/brackets
UNIT 6: THE BLOOD AND LYMPHATIC SYSTEM
A. Overview of the Make-up and function of blood; Typing and Cross-Matching, Clotting and Blood Factors
B. Overview of the Lymphatic system Including Structures and Immunity
C. Vocabulary
D. Abbreviations
E. Diagnostic Procedures Including a Description of the 20 Blood Chemistries
F. Pathological Conditions for Each Division
G. Style Section: spacing, contractions and apostrophes
UNIT 7: NEUROLOGY/THE NERVOUS SYSTEM
A. Overview of the System
1. Description of nerves
2. coverings of the brain and spinal cord
3. structures of the brain and spinal cord
B. Vocabulary
C. Abbreviations
D. Combining Forms
E. Diagnostic Procedures
F. Pathological Conditions
G. Pharmacology
H. Transcription Tips
I. Style Section: Commas and semicolons
UNIT 8: THE SPECIAL SENSES --
OTORHINOLARYNGOLOGY/OPHTHALMOLOGY
A. Overview of the Eye
B. Overview of the Ear, and Brief Description of the Pharynx, Larynx and Sinuses as They Relate to This System
C. System Vocabulary
D. Pathological Conditions, Including a Doctor’s Perspective on the Conditions of this System
E. Diagnostic Procedures
F. Pharmacology
G. Transcription Tips
H. Style Section: Colons, periods, ellipses, question marks, quotation marks, exclamation marks
UNIT 9: THE RESPIRATORY SYSTEM/PULMONOLOGY
A. System Overview Anatomy and Physiology
B. Vocabulary
C. Abbreviations
D. Diagnostic Procedures
E. Pathological Conditions
1. A physicians perspective
2. Upper respiratory conditions
3. Lower respiratory conditions
F. Pharmacology
G. Transcription Tips
H. Style Section: Hyphens and dashes
UNIT 10: THE CARDIOVASCULAR SYSTEM
A. System Overview Anatomy and Physiology
B. Cardiology a Doctors Perspective
C. Combining Forms
D. Vocabulary
E. Abbreviations
F. Diagnostic Procedures
G. Arrhythmias, Heart Sounds and Murmurs
H. Pathological Conditions:
1. Congenital heart diseases
2. Acquired Heart Conditions
3. Diseases of the vascular/circulatory system
I. Pharmacology
J. Spotlight on Cardiology Transcription
K. Style Section: slash marks/virgules; parentheses; other symbols such as plus and minus signs, degree sign, number sign and percent symbol
UNIT 11: GASTROINTESTINAL/DIGESTIVE SYSTE
A. System Overview – Anatomy and Physiology
B. Vocabulary
C. Abbreviations
D. Diagnostic Procedures
E. Pathological Conditions, Including a Doctor’s Overview
F. Pharmacology
G. Transcription Tips
H. Style Section: numbers, Arabic and Roman
UNIT 12: THE ENDOCRINE SYSTEM
A. System Overview Including the Glands, Hormones and Their Functions
B. Vocabulary
C. Combining Forms
D. Abbreviations
E. Pathological Conditions including “What the Doctor Looks Forâ€
F. Diagnostic Procedures
G. Pharmacology
H. Spotlight on Transcribing Endocrinology Including More Info on Cushing Syndrome and Diabetes.
I. Style Section: Sentence types; review of appositives, clauses, and modifiers
UNIT 13: UROLOGY
A. System Overview Anatomy and Physiology
B. Vocabulary
C. Combining Forms
D. Abbreviations
E. Diagnostic Procedures, Including a Breakdown of the Urinalysis
F. Pathological Conditions
G. Pharmacology
H. Style Section: adjectives, articles, adverbs, interjections
UNIT 14: MALE/FEMALE REPRODUCTIVE SYSTEMS, GYNECOLOGY AND Obstetrics
A. Overview of the Male Reproductive System
B. Overview of the Female Reproductive System
C. Obstetrics Overview/Pregnancy
1. Probable/absolute signs of pregnancy
2. Types of Discomfort
3. Signs and symptoms of impending labor
4. True and false labor
D. Abbreviations
E. Combining Forms
F. Vocabulary
G. Various methods for Family Planning
H. Pathological Conditions
I. Diagnostic Techniques/Procedures
1. Laboratory Terms
2. Procedures and Techniques
J. Transcription Tips
K. Style section: Conjunctions, Prepositions and Prepositional Phrases
UNIT 15: PEDIATRICS
A. System Overview including Developmental screening and Growth Patterns
B. Combining Forms
C. Abbreviations
D. Vocabulary
E. Diagnostic Procedures including Heel Puncture, Urine Specimen and Immunizations
F. Communicable/Infectious Diseases
G. Other Pathological Conditions
H. Style Section: Nouns and Verbs
UNIT 16: GERONTOLOGY
A. System Overview
B. Vocabulary
C. Combining Forms
D. Abbreviations
E. Diagnostic Procedures
F. Pathological Conditions, Including an Overview: Changes in the Elderly Person.
(These conditions are broken down by system as follows:
1. Diseases of the blood and lymphatic system
2. Conditions of the cardiovascular system
3. GI tract diseases
4. Endocrine conditions
5. Integumentary system diseases
6. Musculoskeletal system conditions
7. Diseases of the Nervous system/neuropsychiatric conditions
8. Diseases of the eye
9. Otologic conditions
10. Reproductive system diseases
11. Respiratory Conditions
12. Diseases of the Urinary System
G. Style Section: Miscellaneous
UNIT 17: MENTAL HEALTH/PSYCHIATRY
A. System Overview
B. Common Abbreviations
C. Vocabulary
D. Categorizing Mental Disorders
E. Defense Mechanisms
F. Pathological Conditions
1. Amnesic Disorders
2. Disorders related to substance abuse
3. Psychotic disorders
4. Somatoform disorders
5. Sexual Dysfunction Disorders
6. Eating disorders
7. Personality disorders
G. Diagnostic Evaluations/Treatments
H. Style Section: More Miscellaneous
UNIT 18: RADIOLOGY, PATHOLOGY, ONCOLOGY THE HEART OF MEDICINE
A. Radiology Overview
B. The What, When, Where and Why of Pathology
C. Oncology Overview
D. Unit Vocabulary
E. Combining Forms
F. Abbreviations
G. Diagnostic Imaging Studies/Techniques
H. Cancerous Conditions
I. Oncology Pharmacology
FINALE
Concentration on Medical Report Transcription; Meeting together less often for reviewing,
renewing, redoing, and refueling!