Chapter 4 – Transcription Process

1. Chapter 4 – Transcription Process Prepared by: Arlene N. Baratang

2. The transcription process is the integration of listening, keyboarding, and understanding the dictation. Your goal is to synchronize your fingers, foot, and brain into one fluid motion.

3. Sound of Medical Transcription The dictation has a terse, staccato sound, and the dictator has a tendency to abbreviate words and condense sentences wherever possible.

4. Using Reference Materials  Medical Dictionary Dorland’s Illustrated Medical Dictionary Stedman’s Medical Dictionary  Word Books – such as surgery, radiology, cardiology, and laboratory word books.  Pharmaceutical References  

5. Three Popular Drug Books The American Drug Book The Physician’s Desk Reference (PDR) Physician’s GenRx

6. Abbreviation Books Eponyms are adjectives taken from a surname and used to describe diseases, instruments, procedures, and so on.

7. Style Guides For editing, punctuation, and grammar

8. Style Guide Reference Books  AAMT Book of Style for Medical Transcription  Medical Transcription Guide Do’s and Don’t’s  American Medical Association Manual of Style

9. Anatomy & Physiology Books It discusses body structure and function in detail and may include disease processes and disorders.

10. English Dictionary For findings synonyms, antonyms, grammar, spellings, pronunciations, hyphenations, and definitions.

11. Electronic Reference Materials Medical Dictionaries Medical Spellers Homonyms or sound-like words are prime examples where the computer will not recognize the word as misspelled or suggest a substitute word.

12. On-line Resources  www.angelfire.com:MT Daily  www.aamt.org/aamt: AAMT Web page  www2.ncbi.nlm.nih.gov/medline/query_ form.html:Medline website  www.hpisum.com:Perspectives on the Medical Transcription Profession  www.www,com/kamt:Keeping Abreast of Medical Transcription

13. Other Reference Sources  Telephone books  Current magazines  American Hospital Association Guide to the Health Care Field  American Medical Association Membership Directory

14. Word Search  Find a medical word under its main entry.  Diseases may be searched under syndromes.  Procedures may be searched under operations

15. Word Search Medical terms are formed by back formation, such as a noun used as a verb. Medical terms composed of a noun and adjective, i.e. eponyms (Valsalva maneuver, Foley catheter), are found under the noun.

16. Homonyms and Sound-alike Medical Terms  Afferent (n) – moving toward the center  Efferent (n) – moving away from the center.  Anuresis (n) – retention of urine in the bladder  Enuresis (n) – involuntary discharge of urine

17. Homonyms and Sound-alike Medical Terms  Atopic (adj) – displaced  Atrophic (adj) – decrease in the size of a normally developed organ or tissue.  Ectopic (adj) – located away from normal position.  Aural (adj) – pertaining to the ear.  Oral (adj) – pertaining to the mouth.

18. Pointers for Beginnners  Listen to the entire document for any instructions, corrections, and comments.  Stop and start the audio tape as often as desired.  Familiarize yourself with the pronunciation and the meaning of various words.

19. Pointers for Beginnners  Take time to learn the fundamentals of medical transcription.  The transcription process is to listen to a block of dictation, stop, and then accurately transcribe what you have heard.  Think about what you are transcribing.

20. Pointers for Beginnners  Concentration will avoid errors of wrong word choice and inconsistencies in text.  When in doubt about a word, phonetically spell the word and either underscore or bold the word to remind you to verify its meaning. The dictator may repeat the words again, or get a clue from the content of the report.

21. Pointers for Beginnners  The final step is to proofread your document, correct your errors, and print the final document.  It may be helpful to retranscribe (not retype) difficult reports to strengthen your skills.