How can we help?

You can also find more resources in our Help Center.

48 terms

Medical Transcription Fundamentals and Practice Chapter 1 - Pearson Prentice Hall

Chapter 1 Medical Fundamentals
STUDY
PLAY
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