Medical Transcription Fundamentals and Practice Chapter 1 - Pearson Prentice Hall

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Chapter 1 Medical Fundamentals

Three important tools of the medical transcriptionist trade

Dictation and transcription systems, keyboards, the electronic health record

2.The basic four medical reports

History and Physical Examination, Consultation Report, Operative Report, and Discharge Summary.

chief complaint

patient's main problem and the reason that the patient is seeing the physician.

past medical history

all medical and surgical problems from childhood to present

family medical history

the medical condition of parents, family members and other blood relatives

social history

a description of the patient's occupation, lifestyle and habits

history of present illness

A description of the events leading to the the patients current condition

review of systems

the patient's perception of symptoms as the physician asks questions about the major body systems

The skills that contribute to the medical transcriptionist's ability to interpret, translate, and edit medical dictation for content and clarity.

1. English grammar, structure, and style, a knowledge of transcription practices, skill in typing, spelling and proofreading, and the highest professional standards .

physical examination

the physician's objective findings after the patient is examined

Four reasons why laboratory tests are done

1) Disease diagnosis in ill patient,
2) Hidden disease screening,
3) Blood level monitoring of medication
4) To confirm freedom of disease

four types of drug forms

Tablet, Capsule, Gel, and Cream

Four environments where transcriptionists work

5.Hospitals, physician practices, home offices and clearinghouses

Four routes of drug administration

Oral, Rectal, Vaginal, Topical

toward the front of the body

anterior

toward the back of the body

posterior

toward the midline

medial

toward the side

lateral

away from the center; toward the periphery

distal

within the body

internal (or deep)

toward the body surface

superficial

the study of

-logy

tumor

-oma

toward

ad-

development or form

-plasia

inflammation of

-itis

pain

-algia

without

a-

discharge, flow

-rrhea

enlargement of

-megaly

across

trans-

3.The healthcare record is used

1) to plan, communicate , and evaluate the quality of care given to each patient
2) to serve as "proof of work done" in order to facilitate medical reimbursement from health insurance companies to providers
3) as medico legal protection for the patient, facility, staff, and physician

self

auto-

a disease condition

-pathy

within

intra-

new opening created surgically

-stomy

beside or near

para-

cutting out

-ectomy

increased in amount

hyper-

an abnormal condition

-osis

an instrument used to record

-graph

painful or difficult

dys-

a surgical repair

-plasty

process of examining visually

-scopy

located above

supra-

making an incision into

-tomy

coming after

post-

false

pseudo

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