Medical Trans Chapter 1

59 terms by winniepoohbear

Create a new folder

Advertisement Upgrade to remove ads

What is medical transcription?

AAMT

American Association for Medical Transcription

allied health professional team

Medical transcriptionist, nurses, office manager and staff, PA's and medical assistants and others whose primary task is to work with the physician in providing medical care are part of this team.

anatomy and physiology

The study of structure and function of the body and its systems

chain of command

The hierarchy of departments a transcriptionist must go through to pick up and turn in their work, or if they have questions about the dictation.

clerk

Office assistant with secretarial and other office duties.

confidential

Undisclosed and private

dictation

Words spoken, or dictated, for the purpose of writing them down.

discipline

control over one's behavior

document

one or more pages of text

editing

Assembling or reassembling a word, group of words, or document by cutting, pasting, adding, deleting and rearranging

ergonomics

The science of tailoring the transcription process to the transcriptionist's own anatomical, physiologic and psychological characteristics, in a manner that will blend efficiency with well being.
This includes: being physically and mentally prepared for the work at hand; being familiar with specialized tools that can aid in transcription, being aware of physical and mental strengths and weaknesses that can be helpful or detrimental; being knowledgeable of hand, back and other bodily exercises to minimize and prevent workplace injury and exhaustion; and having in place support systems such as AAMT, colleagues, close friends and confidants so feelings can be shared and feedback can be received.

hand-eye coordination

Having the hand and eye work in conjunction without focusing on either

health information team

Clerks, secretaries, technicians, medical librarians and other medical personnel who collect, process, sort, store and retrieve medical information and health care data.

Hippocratic Oath

...

independent contractor

One who is self-employed with a contractual agreement to perform specific tasks

keyboarding/word processing

Saving text in computerized form in an internal memory bank or on a magnetized diskette or tape instead of on a piece of paper.

language mechanisms

Used in editing; include using correct words, grammar, punctuation, numbers, abbreviations, plurals, possessives, compound words, pronouns, and contractions.

medical records

Records describing an encounter between a health care provided and a patient; documents governed by laws and scrutinized by members of the legal community.

medical records supervisor

A staff member who supervises the work and personnel of a medical records department.

medical terminology

Words specifically related to the medical field

medical transcription

Act of taking written or dictated medical information and producing a permanent, uniform and legible record of that information in keyboarded form.

medical transcription service

Company that provides medical transcription services for an unassociated and independent facility or client.

medical transcriptionist

A person who transcribes oral and / or written medical dictation, producing permanent and uniform medical records and information.
Part secretary, part translator, part editor and part medical assistant, also must be language specialists.

medicine

The preservation of health, prevention of illness and the treatment of disease processes, one of the most basic elements of life.

mental deciphering

Figuring out complex concepts or terms in the mind without having to write them down

pathophysiology

The study of how body functions are affected by disease

pharmacology

The study of drugs and medicines and their effects on living things

proofer

An allied technician who proofreads the transcribed report

self-commitment

Pledging to achieve one's goals

speech idiosyncracies

Regional dialects, accents, colloquialisms, foreign language variations and speech impediments.

subpoenaed

Medical records have the potential for this: ordered to be produced in a court of law.

transcribe

To change into writing. Changing oral dictation into written form.

word breakdowns

Phonemics (keys to pronunciation), etymology (study of word origins), phraseology (study of sentences and pharases), use of acronyms (words that are made from the first letter of a group of words, homonums (words that are spelled and pronounced alike, but are different in meaning, synonyms (words with similar meanings), and antonyms (words with opposite meaning)

work environment

Environment in which a medical transcriptionist performs his or her duties; many factors depend on the physical proximity of the dictator to the transcriptionist; in a hospital environment, they have little direct contact with the dictating physician, and medical records are used as an intermediary.

Describe the first historical form of medical documentation

Early Native Americans used a crude form of documentation called "petroglyphs", which were pictures written on rocks but were confusing and misunderstood. Later, around the fourth or fifth centuries B.C., more advanced documentation started by the Greek Physician Hippocrates in about 500 B.C.

Who was Hippocrates, and how was he important in the development of medical documentation?

Hippocrates was a Greek Physician who wrote a collection of works known as the Hippocratic Corpus, which included the Hippocratic Oath. Upon entering the field of medicine, physicians take the Hippocratic Oath. It is accepted that Hippocrates began the art of practicing medicine as a documented scientific method.

What sentence in the Hippocratic Oath refers to confidentiality in medical records information?

"Whatever in connection with my professional practice, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that al such should be kept secret."

List at least two requirements and two skills that a medical transcriptionist must possess to be successful

a. Requirements: Discipline and Self-commitment
b. Skills: Listening, mental deciphering, hand-eye coordination and concentration

Describe editing and how it can transform dictation

Editing is assembling or reassembling a word, group of words or document; this process can transform dictation by making it grammatically correct, make clear, concise and more logical expressions of the same information.

What is the importance of hand-eye coordination in medical transcription?

Having the hand and eye work in conjunction without focusing on either

List the four major medical transcription environments

Hospital, medical office, medical transcription service and home-based transcription service.

In which environment does the medical transcriptionist typically have the most contact with the physician/dictator?

A medical transcriptionist has the most contact with the physician within the medical office work environment

In which environment does the medical transcriptionist have the least supervision?

In a home-based independent transcription service.

A medical transcriptionist and a medical __________ are one in the same.

Transcriber

The ____________ Oath instructs those practicing in the medical field to refrain from divulging work-related information

Hippocratic

Medical transcriptionists are part secretary, part translator, part editor and part _______ _________

Medical assistant

Etymology

The origin or history of a word

The physician is _____ always available to directly answer a medical transcriptionist's questions

not

A medical transcriptionist must _________ work independently without supervision

sometimes

A medical transcriptionist is ______ accountable to someone else, whether it be a supervisor, a physician, or another facility

always

In the medical clinic, a _______ usually proofreads the medical transcriptionist's work

Proofer

The earliest foundations of medicine were based in ________, practiced thousands of years ago in the _____ age.

religion, Stone

Later, after the stone age, medicine was practiced by medicine men or _______

shamans

To early Native Americans, medicine included anything have a ________ or __________ orientation, from objects such as bows, arrowheads or stones, to injuries such as a lacerated arm, bruised leg or wounded knee.

religious, therapeutic

Petroglyphs

picture-writing on rocks

The art of practicing medicine as a documented scientific method was begun by the Greek physician _________ in about ___ B.C.

Hippocrates, 500

Hippocrates authored a collection of works known as the Hippocratic _____, which includes the ___________ ____

Corpus, Hippocratic Oath

Physicians take this upon their entrance into the medical field

Hippocratic Oath

Can be document and become part of a patient's medical record.

A written note in a patient's chart
A letter of thanks to a referring physician or law office
A phone conversation to a pharmacist concerning a patient's medication

Please allow access to your computer’s microphone to use Voice Recording.

Having trouble? Click here for help.

We can’t access your microphone!

Click the icon above to update your browser permissions above and try again

Example:

Reload the page to try again!

Reload

Press Cmd-0 to reset your zoom

Press Ctrl-0 to reset your zoom

It looks like your browser might be zoomed in or out. Your browser needs to be zoomed to a normal size to record audio.

Please upgrade Flash or install Chrome
to use Voice Recording.

For more help, see our troubleshooting page.

Your microphone is muted

For help fixing this issue, see this FAQ.

Star this term

You can study starred terms together

NEW! Voice Recording

Create Set