Medical Transcription 10 Lecture Slides.pdf

Medical Transcription References

1. Medical Terminology IV
Week 11: Medical Transcription References
MEDICAL TRANSCRIPTION
DR EBENEZER ODURO ANTIRI

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Knowing where and how to quickly find obscure terms or unfamiliar phrases is a crucial
skill that can make the difference between struggling or thriving as an MT. Information
you’ll have to look up sooner or later (and often both) includes:
•1. Medical words and phrases you haven’t heard before
•2. Names of medical and surgical equipment and supplies
•3. Medical abbreviations and acronyms
•4. Brand and generic drug names and dosages
•5. Laboratory tests and normal values
•6. How to format a phrase or document to conform to medical transcription
standards
Key Medical Transcription References
M E D I C A L T R A N S C R I P T I O N R E F E R E N C E S

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•Specialized references exist for every one of these tasks.
•Some of these are specifically created and designed to make an MT’s job easier;
others are created for medical professionals or laypeople but are helpful to MTs as
well.
•As your career progresses, you’ll develop a customized go-to reference list of your
own, keyed to the types of reports you transcribe and your personal preferences.
Key Medical Transcription References
M E D I C A L T R A N S C R I P T I O N R E F E R E N C E S

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•Here are the five primary resources MTs rely on to quickly hunt down a mystery
word or phrase or verify a word's spelling:
•1. Electronic medical spell checkers
•2. Print and electronic medical dictionaries
•3. Specialty word and phrase books designed specifically for medical
transcriptionists
•4. Websites and search engines
•5. Fellow MTs
Sources of Medical Transcription References
M E D I C A L T R A N S C R I P T I O N R E F E R E N C E S

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•Certain publishers and series have a proven track record of creating excellent medical
references. Among them are the following:
•1. The Stedman’s series of medical references published by Lippincott, Williams &
Wilkins are of the top options on any medical subject.
•2. Saunders, an imprint of Elsevier, publishes specialty books designed for, and often
authored by, medical transcriptionists.
•3. The Association for Healthcare Documentation Integrity (AHDI) industry association
publishes the standard transcription style guide used by MTs and medical transcription
certification exam preparation guides.
•4. Health Professions Institute (HPI) specializes in medical transcription training
materials.
Sources of Medical Transcription References
M E D I C A L T R A N S C R I P T I O N R E F E R E N C E S

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The first step to hunting down a mystery word or phrase is to assess the surrounding
dictation for clues as to what type of word or phrase you’re looking for.
1.What report type and section heading does it appear under?
2.Is it linked to a particular specialty (for example, cardiology, obstetrics, orthopedics)?
3.Is it related to a body part or system?
4.What part of speech is it (noun, adjective, verb, and so on)? Could it be a piece of
medical equipment or a drug name?
5.Could it be an acronym pronounced as a word? (For example, CABG is frequently
dictated as “cabbage.”)
Tracking Down Medical Words and Phrases
M E D I C A L T R A N S C R I P T I O N R E F E R E N C E S

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Medical dictionaries offer a lot more than a way to look up a definition or spelling of a
word that you already know; they also help you find multipart words and phrases when
you can recognize one part of it but not the other.
There are two commercial (not free) medical dictionaries MTs frequently use:
1. Stedman’s Medical Dictionary, published by Lippincott, Williams & Wilkins
2. Dorland’s Illustrated Medical Dictionary, published by Elsevier Saunders Figure 8-1:
Fracture listing from Dorland’s Illustrated Medical Dictionary.
You only need one or the other, not both.
Mining a medical dictionary
M E D I C A L T R A N S C R I P T I O N R E F E R E N C E S

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•Medical word books, which come in print and electronic versions, are lists of words
and short phrases organized in alphabetical order. Their sole purpose is to help you
speedily locate words and phrases and spell them correctly, and they do it well. They
don’t include definitions.
•Medical word books come in two flavors:
•1. General purpose: The general-purpose books are designed for all specialties.
Although that may sound very convenient, in reality it’s quite limiting because depth
into individual medical word categories is sacrificed to achieve greater scope.
•2. Specialty: The specialty books, on the other hand, bypass the big picture in favor of
depth on a single topic or a pair of closely intertwined topics.
Medical word books
M E D I C A L T R A N S C R I P T I O N R E F E R E N C E S

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•Both types of word books contain multiple listings for a phrase—often one under each
word in the phrase. If you can get a word or two of a short phrase, you can often use a
medical word book to quickly and definitively identify the full phrase.
•For example, imagine you’re transcribing a cardiology consultation, and the patient is
diagnosed with “inferior walrus infarction.” You replay it again and hear the same
thing. If you have a cardiology specialty word book such as Stedman’s Cardiovascular
& Pulmonary Words on hand, you can consult it and quickly resolve your confusion.
•1. Look up infarction, and you’ll find inferior wall infarction.
•2. Look up inferior, and you’ll find inferior wall infarction.
•3. Look up walrus, and you’ll find... nothing, of course!
Medical word books
M E D I C A L T R A N S C R I P T I O N R E F E R E N C E S

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•In order to produce the clearest medical document possible, MTs expand acronyms,
abbreviations, and other verbal shortcuts to eliminate misinterpretation of their
meaning.
•Many acronyms have multiple potential expansions.
•The best way to look these up is to use a specialty book or trusted website that
specializes in medical acronyms.
•The number-one option is Stedman’s Abbreviations, Acronyms & Symbols.
•Another reference, less comprehensive and focused but still useful, is
AcronymFinder.com (www.acronymfinder.com). If you have a specialty medical word
book that covers the relevant specialty or word category, that’s another great place to
look.
Abbreviations and acronym finders
M E D I C A L T R A N S C R I P T I O N R E F E R E N C E S

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•Transcribing medications correctly is absolutely critical.
•Most dictators take special care to be clear when dictating a medication list, but there
are still plenty of occasions when you’ll have to use references to clear up murky
spots. Some drug references are:
1.Quick Look Drug Book (QLDB), by Leonard L. Lance (Lippincott Williams & Wilkins)
2.Drugs.com
3.Physician’s Desk Reference (PDR)
Drugs and Dosages
M E D I C A L T R A N S C R I P T I O N R E F E R E N C E S

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•Transcribing medications correctly is absolutely critical.
•Most dictators take special care to be clear when dictating a medication list, but
there are still plenty of occasions when you’ll have to use references to clear up
murky spots. Some drug references are:
1.Quick Look Drug Book (QLDB), by Leonard L. Lance (Lippincott Williams & Wilkins)
2.Drugs.com
3.Physician’s Desk Reference (PDR)
Clearing up cloudy medication details
D R U G S A N D D O S A G E S

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•Drugs are frequently dictated as lists. An individual drug typically consists of up to five
parts. Use the segments you hear clearly to help track down the parts you’re unsure
of.
•Although this is the standard format, a dictator may not include all the segments, or
may include them in a different order. Thus, if you hear:
•atenolol 50 milligrams, one__b.i.d.
•It’s likely the mystery word describes either the dosage format or the administration
route. Listen again for “tablet,” “by mouth,” or “p.o."
Drugs and Dosages
M E D I C A L T R A N S C R I P T I O N R E F E R E N C E S

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•To check up on lab dictation you’re unsure of, follow these steps:
1.Identify the name of the test group the result most likely belongs to, such as blood
count, thyroid panel, or coagulation profile.
2.If you’re not familiar with the group, a search for lab tests related to the conditions the
patient has may turn it up.
3.Determine which values in that group you haven’t yet transcribed.
4.These are your prime candidates.
5.Look up the test group in your reference and scan through the name/value pairs it
typically includes to see if your mystery item is present.
6.Pay particular attention to the normal results range of that test and the value you think
you hear to be sure they correlate.
Laboratory Tests
M E D I C A L T R A N S C R I P T I O N R E F E R E N C E S

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•Favorite MT references for identifying and confirming laboratory test names and
expected normal values include the following:
•1. Lab Tests Online (www.labtestsonline.org): This free resource is great for
identifying lab tests by formal or informal name or by medical condition. It’s not much
use for checking reference ranges, however.
•2. Wikipedia’s Reference ranges for blood tests entry
(http://en.wikipedia.org/wiki/Reference_ranges_for_commo n_blood_tests): This page
includes an extensive list of reference ranges for blood tests. It also links to reference
ranges for additional lab test types, such as urinalyses.
Laboratory Tests
M E D I C A L T R A N S C R I P T I O N R E F E R E N C E S

16. Any questions?
Thanks!
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