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.
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 .
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 environments where transcriptionists work
5.Hospitals, physician practices, home offices and clearinghouses
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