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Medical Trans Chapter 1

What is medical transcription?
STUDY
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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