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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


toward the back of the body


toward the midline


toward the side


away from the center; toward the periphery


within the body

internal (or deep)

toward the body surface


the study of






development or form


inflammation of






discharge, flow


enlargement of




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



a disease condition




new opening created surgically


beside or near


cutting out


increased in amount


an abnormal condition


an instrument used to record


painful or difficult


a surgical repair


process of examining visually


located above


making an incision into


coming after




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