Medical Transcription Fundamentals: Where Success Takes Root Second Edition

Book Preface

A medical transcriptionist, whether working in an office or in a home-based environment, is an integral part of a healthcare team. Far more than a typist in the medical field, a medical transcriptionist must be familiar with the terminology used in every medical specialty and must be able to produce the documents and reports required by each specialty in a professional and competent manner. These reports are the foundation of patient care and not only comprise a patient’s complete record, but also track a patient’s medical history and determine any future treatment.

Medical Transcription Fundamentals, Second Edition, a holistic approach to the study of medical transcription, is a comprehensive, yet concise, manual written by a practicing medical transcriptionist for student medical transcriptionists. This conversational approach, filled with practical, “from-the-trenches” tips and advice, makes this book particularly valuable to the new transcriptionist entering the field. Compatible with the Association for Healthcare Documentation Integrity (AHDI) Model Curriculum and designed with the adult-vocational and postsecondary school student in mind, this product meets the needs of both students and instructors. It can serve as the primary textbook in a short-term medical transcription course.

Alternatively, it can be incorporated into a more comprehensive medical skills program in which a course in medical transcription may be one component of the curriculum. This text can also be used for independent, on-line study. After completing the exercises and activities in this book, students will be able to prepare standard medical reports accurately and efficiently. They will also be well versed in the fundamentals of anatomy and medical terminology as used in various medical specialty practices. The majority of medical transcription textbooks currently on the market focus on general simulation and transcription activities. Most are not written by medical transcription practitioners and do not cover the issues relevant to students entering this field. Those textbooks that do, typically do more flexing of vocabulary prowess rather than simply explaining the topic in a manner that students can easily comprehend. Furthermore, these texts fail to follow up with adequate skillbuilding exercises to reinforce an understanding of the concepts and terms associated with each specialty. Medical Transcription Fundamentals identifies the specific knowledge, skills, and education required for medical transcriptionists and outlines the responsibilities associated with the occupation. With a light, conversational writing style that is easy to read and understand, this product lays a solid foundation for a medical transcription career by providing a conceptual understanding of general medical terms and various medical specialties in a way that is easily remembered. It further encourages independent thinking and provides practice in working with the concepts covered in each chapter through a variety of challenging exercises and activities.

NEW TO THIS EDITION

The second edition of Medical Transcription Fundamentals builds on the original edition of learning tools with the addition of two new chapters not covered very thoroughly in other products: Surgery and Pharmacology. The surgical chapter serves as a foundation on which to build a student’s knowledge of preparing surgery reports in the acute care setting. This chapter covers the general concepts of surgery, along with terms typically encountered by a medical transcriptionist in transcribing operative reports, including patient positioning, anesthesia, fluids, tools and instruments, wound closures and coverings, formatting issues, and common surgical phrases, all of which will enable students to produce accurate, grammatically correct documentation of surgical procedures. The pharmacology chapter contains a comprehensive review of the purpose and history of drugs, medication descriptions, regulation, development, and the terminology used to indicate drug forms, types, and routes of administration that are transcribed regularly by medical transcriptionists in nearly every medical report.

In addition, as the transition to general use of the electronic health record (EHR) is being mandated by the
federal government as an effective means of lowering the nation’s healthcare costs, it is vital that medical transcriptionists become proficient in the use of speech recognition technology, and this is a highly desirable skill for medical transcriptionists. To that end, this edition provides hands-on practice with speech recognition editing exercises for each of the specialty chapters using authentic speech-recognized drafts so that the student can develop these skills. The experience provided by exposure to this new technology can help students develop the confidence that these new skills will serve them well when they begin working.

In addition, the specialty sections now offer special ancillary activities called cloze exercises to help students test listening and reading comphrension. Simply put, a cloze exercise is a “fill-in-the-blank” document that consists of sentences of a report with several words missing. Instead of transcribing the report, students listen to the report as it is being dictated and supply the missing wordor words by listening and comprehending the context of what is being said from the sentences dictated. These exercises enable students to use critical thinking skills to supply words that are missing from text by understanding the story being told. One of the skills of a competent medical transcriptionist who encounters terms they are not familiar with is to try to determine the missing word from the context of the report, or to be able to streamline researching for the word by understanding the topic being discussed. These exercises give students practicing in hearing and researching challenging medical terms. Finally, this edition incorporates the latest styles, forms, and grammar and usage specific to the profession from The Book of Style, Third Edition by AHDI.