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Quality medical dictation affects the accuracy and turnaround time of transcriptions which directly impacts patient care and reimbursements. This article will provide you with the Top 10 tips for successful medical dictation and transcription. Whether you are a small practice or a community health center administrator, the following will be beneficial to you.
Your practice can benefit greatly by improving the precision of your medical dictation skills. Good medical dictation will bring you savings, as well: poor dictation consumes time and labor, increasing overall documentation costs. Finally, quality dictation can even help you legally: fewer transcription mistakes caused by poor dictation equate to fewer errors in patient care.
By incorporating the following top 10 tips for successful medical dictation, you can accelerate the time it takes medical transcriptionists to learn the style of your dictation, as well as improve their accuracy – all the better for you to run an efficient and high quality medical practice – a win-win for all.
1. At the start of your dictation, gather any papers, reports that you might need for your reference.
2. Dictate as if you are speaking to the patient in an exam room, speaking clearly so the Medical Transcriptionist will understand you without error.
3. Speak at a steady pace and not too loudly or softly. Keeping the recorder approximately 8-10 inches from your mouth will help improve clarity. Always move your face away from the recorder to sneeze or cough.
4. Minimize noises including the TV or radio, eating, drinking, chewing gum, shuffling papers, opening drawers, rearranging your desk or making loud noises as they can be very distracting to the medical transcriptionists. Likewise, do not dictate in a crowded room. The background noise is distracting and you may be sharing protected health information inadvertently.
5. Avoid multitasking while performing dictations. Use the pause button if you would like to take a sip of water or sort out documents. Do not dictate while driving. The sound quality is usually poor, not to mention that it is dangerous.
6. Identify yourself and state what type of report you will be dictating. Detail any special instructions at the beginning of the dictation. State, and then spell full details of information such as the patient’s full name and proper mailing address on letters.
7. During the dictation be as specific as you can with spelling, phrasing, formatting and ‘normals’. Spell the names of patients that you think the Medical Transcriptionist may not understand (i.e. ‘Amy’ spelled instead as ‘Aimee’), as well as local names or cities. Clearly spell words that may not be commonly used in the medical field, including new pharmaceuticals or treatments and unusual words representing diseases, drugs, or procedures not normally found in the mainstream of your daily work or specialty. Use the same phrases in each of your report types and follow the same order of headings whenever possible. Furthermore, be specific when inserting ‘normals’. If you need to change any part of the normal, please indicate exactly what information the medical transcriptionist should delete and where to insert changes.
8. Include punctuation, especially when starting new paragraphs, and include ‘open’ and ‘close’ quotation mark instructions.
9. Avoid using a lot of ‘ahhhs,’ ‘ums,’ ‘ers’ and ‘uhhhs.’ They can be confused for the letter ‘a’.
10. While cellular phones are convenient, the sound quality is usually not ideal. Land lines will give the medical transcriptionist a better quality recording.
With these practical medical dictation tips, you will help your medical transcriptionist provide you with highest quality service in an expedient manner. High quality patient care, accurate records, accurate billing, lower costs, and fewer legal issues all begin with your clear and precise dictation – a small consideration with very large and far-reaching benefits to your practice and your patients.
How many times have been to a massage therapist, a doctors office, even your local mechanic and been told something in a language you don’t understand. Even though English was spoken, the words just made no sense to you. Like most people you politely smile, nod your head in agreement and leave wondering just exactly what he meant.
You may have done this because you did not want to look “stupid” in front of the person who was talking to you. You have probably heard this before, but it needs saying again – “There are no stupid questions!” Especially when it comes to your health. If you don’t understand what you are being told, ask for it to be repeated in a way that you can understand.
Professional people use a language all their own. Depending on what profession the person belongs to, dictates the language they use. When the professional is dealing with the general public, they sometimes forget that they need to use “laymans” terms in order to be understood. A good professional will take the time to make sure you understand what you are being told. They have to, if they want your business. If they are unwilling to make themselves clear to you, then it might be a good time to seek another opinion.
In the massage profession, a therapist is taught the specific terms used in massage. Once a massage therapist learns these terms, they tend to use them. One reason is so that there can be no confusion as to exactly what they are talking about. That is of course if they are talking to another massage therapist. Sometimes they forget that they are not always talking to someone who understands massage terminology.
In this age of the Internet and the Information Super Highway a lot of people are educating themselves. I believe this is an excellent thing to practice. The massage terminology I am going to list is not definitive, but only some of the more common terms. I will attempt to explain each one in plain English.
Types Of Massage
Different Strokes For Different Folks
All Knotted Up
There are different terms for the different conditions of a muscle. These can vary wildly and mean different things to different people. You might hear your therapist say “That’s a ropey knot.” What he may be referring to is a long tight band of muscle. Two forms of knots that have definitive meanings are trigger points and tender points.
Some Miscellaneous Terms
As stated earlier, this is not a definitive list of massage terminology. These are some of the more common terms used by most massage therapists. The next time your massage therapist uses any of these terms; you will know what he is talking about. You can be proud that the power of educating yourself has paid off!
When researching your family history you may come along death certificates with the cause of death listed as something you have never heard of. Back in the day there were a lot of medical terms for diseases and illnesses that don’t pertain to today and are no longer used.
This article is a short story about a young woman visiting with her family using those old time medical terms to describe their ailments. After reading the story you will find a list of those terms with their meanings.
May 15, 1920. Today I went out for a walk to visit some kinfolk. First I stopped at Grandmas house. She is anile and her bone shave has been bothering her, so I wanted to check on her. She was doing well today. Grandma is a good cook and she fixed me eggs and sausage with biscuits and gravy for breakfast. Sometimes, though, I get Grocers Itch after eating there. Don’t know why.
Her chickens lay the biggest and best eggs you’ve ever tasted. Her sausage came from her old sow Elly, who was slaughtered last week. Grandpa, who is a little decrepitude, did the slaughter with the help of Uncle George and Uncle Billy. They do most of the butchering for the folks down in the holler.
Grandpa has been down in the bed with Hectical Complaint and Blackwater Fever. He is starting to mend but doesn’t have all his strength back yet. Grandma was afraid he had come down with Putrid Fever, but that didn’t prove so. I was satisfied that both are getting along ok.
Uncle George, who lives with Grandma and Grandpa, was out milking their only cow, Bessie. Uncle George is the wild one of the family. He is a ladies man and goes out drinking most nights. I thought he would quit that drinking after having the Horrors and Barrel Fever for a spell. I heard gossip through the grapevine that some of his lady friends are mad at him. They say he has the French Pox and gave it to some of them. One of the ladies even gave the Bad Blood to her husband. I heard too, that her husband is going to use his shotgun on the ‘man’ that gave it to her when he finds him. Oh my.
I went on down the road to see my Aunt Mary and Uncle Billy who had just birthed a baby girl a few months back. Their whole family has had some kind of sickness lately. Aunt Mary came down with Milk Leg after giving birth and can hardly walk. Uncle Billy has Corruption to both hands from the Ambustio he got from boiling water they use during slaughtering. The poor baby had Diary Fever and a Worm Fit from cutting teeth.
I returned home hoping and praying that all is going to be well.
Medical Terms and Meanings:
– Anile = “A weak old woman.” Also applied to senility from old age.
– Bone Shave = Sciatica.
– Grocers Itch = Skin disease caused by mites in sugar or flour.
– Decrepitude = Feebleness due to old age.
– Hectical Complaint = Recurrent Fever.
– Blackwater Fever = Dark urine associated with high temperature.
– Putrid Fever = Diphtheria.
– Horrors = Delirium Tremens
– Barrel Fever = Sickness from immoderate drinking.
– French Pox = Syphilis
– Bad Blood = Another name for Syphilis.
– Milk Leg = Postpartum thrombophlebitis.
– Corruption = Infection.
– Ambustio = A burn or scald.
– Diary Fever = A fever that lasts one day.
– Worm Fit = Convulsions associated with teething, worms, elevated temperature, or diarrhea.
In addition to learning the unique language used by medical professionals, a medical transcriptionist must also be an expert on English grammar and spelling. As if that isn’t enough to remember, there are styles and formats that are unique to the medical field; not being familiar with these accepted guidelines can generate quality assurance issues for a transcriptionist and the medical records and impact patient safety.
Homonyms are difficult for many English speakers to master, but when they occur in medical language, it becomes even more tricky. For example: ileum and ilium. These are medical terms that refer to two different anatomical areas. In order to select the correct spelling, it’s necessary to be familiar with the anatomy and to look at the context in which the word occurs. Experienced transcriptionists develop a system of mnemonics that assist them in finding the correct spelling of a homonym.
The ilium is a bone in the pelvis; in lay terms, the hip bone. The ileum is part of the small intestine. An easy mnemonic is to remember that both hip and ilium have the letter “i”. After that, a transcriptionist needs to look at the context of the word use in order to apply the appropriate term and spelling.
Although not considered homonyms, there are terms that sound like something else entirely, resulting in a transcription error, usually by an inexperienced transcriptionist. “Below knee amputation” is frequently mistaken for “baloney amputation.” An experienced transcriptionist knows that there is no such thing as a “baloney amputation,” regardless of whether or not it sounds like that is what a dictator is saying! In medical transcription, these are referred to as “sounds-like” errors.
Abbreviations are very common in medical terminology. They allow physicians and other healthcare professionals to document records quickly. Unfortunately, there are many terms that can apply to one abbreviation, which can lead to mistakes. The Institute for Safe Medication Practices (ISMP) has published a list of terms and abbreviations that can be misread and advised that these be written or transcribed in specific ways in order to avoid confusion.
In medical terminology, the abbreviation OD or o.d. can be either right eye – or once daily. It’s essential for a medical transcriptionist to know that the ISMP recommends that neither abbreviation be used, that it be written out as “right eye” or “daily,” as appropriate.
Abbreviations may also be misread, as one letter closely resembles another, even in a typewritten report. The ISMP also recommends that the abbreviation “IU” (International Units) not be used, as it can be mistaken for “IV” (intravenous).
There are also guidelines governing abbreviations for measurements. The use of the abbreviation “cc” (cubic centimeters) is common, but not advised; documentation specialists are advised to use the abbreviation “mL” (milliliters) instead, as “cc” can be misread.
Documenting for accuracy and clarity
The core guidelines for medical transcription style and format are geared towards documenting the record with accuracy and clarity so that other healthcare professionals can easily find and read the information they need to make healthcare decisions, while feeling confident that the record is accurate insofar as the transcriptionist is able to interpret the dictator’s spoken word and intent.
Nasal sinus surgery in medical terms can also be referred to as ethmoid sinus surgery or at times endoscopic sinus surgery can also be referred to as nasal sinus surgery because the endoscope or a thin optic tube is inserted through the nose.
Firstly, in order to understand this surgical procedure of nasal sinus surgery one needs to first know what is exactly an ethmoid sinus allergy/infection is and also where is this sinus located. Ethmoid sinus is located next to the eye and near the nose; and when this part is infected by bacteria; which is the primary cause in most cases this area swells. Swelling leads to narrowing down of the channel that lies between the nose and the mentioned sinus and a self-formed barricade disables the free flowing of water, mucus and other secretions. Similarly in cases of frontal sinus and maxillary sinus the infected areas swell and cause problems.
Nasal sinus surgery not only helps in getting relief from uneasiness and discomfort that complements sinus infection but also is painless. But nasal sinus surgery should only be performed after it is advised by an E.N.T specialist/ otolaryngologist and under the supervision of hands with expertise because of the sensitive location of this particular sinus in concern. The sensitive location increases the chances of damage to both eyes as well as brain. That is the reason why in nasal sinus surgery is either performed with the help of an endoscope in general cases i.e., by Endoscopic Sinus Surgery or Functional Endoscopic sinus surgery (FESS) or in severe chronic cases by Image guided surgery.
Image guided surgery is a comparatively new technique that rules out doubts that would have cropped up with the idea of inserting a tube in a sensitive area where there is a possibility of irreversible damage to the tissues and nerves that are connected to the brain or eyes. The Image guided surgery is carried out with the help of a three dimensional mapping system which is bringing together of CT scan and real-time information that gives the exact location of the infected area and the infrared rays are used as surgical tools.
Nasal sinus surgery not only subdues the discomforts caused by infected sinuses but also is the last resort in cases of chronic or severe chronic sinusitis.
There are numerous websites on the internet today that will serve you well as a medical dictionary. Although there may be a lot of them that doesn’t mean that they are going to fix any problems that you have. Generally speaking looking up medical diagnosis and medical dictionary online can get lead you down a path of self diagnosis and self resolution. That can be extremely dangerous.
If you think about it anyone could put up a site claiming to be of great medical knowledge. There is really no way that you can know whether or not the advice you are following is true. Don’t play with your health. It can lead to your death, and I don’t think anybody wants that. If you are putting off going to the doctor because of past experiences or long waits; you excuse no longer bares weight.
If you are holding back because you are still stuck in the public health system then I can understand that, but it is time to take charge of your health, and yes that means shelling out a couple bucks a month for the private care and coverage. Stop relying on self diagnosis and medical dictionary online to give your answers. That can be hazardous to your health. Suck it up and invest in your health a little bit. It won’t hurt; actually it should make you feel pretty good knowing that you are covered by awesome coverage and in turn care. No more long waits; so no more excuses.
Choosing a doctor is not always easy. You first need to find a doctor that takes your insurance. If you have medicare or medical then it may takes some time to find a perfect match. Not all doctors accept this but you can be assured that there are many that will.
First you need to make a list of doctors that you want to visit. You may find doctors by searching online in your area or you may get recommendations. After you have a list then you need to call there office and see if they accept medicare of medical. The ones that do not you can mark them off your list.
Next you want to take the list of doctors that do take your insurance and interview with them. It is important to feel comfortable with your doctor and you should be able to talk with them about anything. There needs to be level of comfort and trust, so make sure that you check out several doctors before making a final decision.
Finding a doctor can be hard enough but getting one that takes medicare or medical can takes you some time. It is important that you find a doctor that not only accepts your insurance but that they are one that you feel comfortable with.
Finally once you spend the time searching for a doctor that fits you needs then you will feel great that you took the time to have a great provider. There are many doctors that accept this type of insurance. It is always a good idea to check with family and friends to get a reference because they can tell you if there doctor is good or not.
Apart from the wide application of medical terminology in the medical field there is a lot of demand for the people that are working depending on this field to get to know the medical terms themselves. Medical transcription is one department where it is very important for the transcriptionist to be aware of the medical terminology. The work of the medical transcriptionist is to type out medical reports as dictated by the doctor, which will contain anything from a surgical procedure through prescription medication. If a transcriptionist is going to make a minor error it can lead to a lot of complications.
The work strategy of a medical transcriptionist is never complete without the use of medical terminology. Truly, medical terminology is the foundation stone for the medical transcriptionist. Even the most trained medical transcriptionist would need to refer the medical terminology when they are unsure about a particular work.
Referring medical terminology books is an important attribute that adds to the skill level of any medical transcriptionist. Since the transcriptionist does the typing based on contextual thinking they need to correlate the terms and dictations based on the meaning of the medical terminology dictated by the doctor.
In cases where the doctor dictates something like hypoglycemia and the transcriptionist is of the doubt that it might be hyperglycemia then if they are going to key in hyperglycemia it is a fatal error. The medication and treatment methodologies might greatly vary. Hyperglycemia is increase in blood glucose and hypoglycemia is going to be decrease in blood sugar. In cases where the patient is being taken care of by multiple doctors, the doctor that is prescribing the medication of varying the medication might take clue of the medical terminology of “hyperglycemia” in the transcription to make the prescription.
If a medication for hyperglycemia is prescribed for a hypoglycemic condition, it can even lead to coma or the patient! Such fatal assumption errors in medical terminology are avoided by timely reference habits by the transcriptionist. The transcriptionist refers the two terminologies hyperglycemia and hypoglycemia and they learn their meaning. They refer to the laboratory data and look in to the glucose level. If the glucose level is less than normal the appropriate term for it would be hypoglycemia because hypoglycemia means low level of glucose. They listen to the tape again and confirm it is hypoglycemia and key it in there, thus preventing a major treatment error or even insurance claims decline. So, understanding medical terminology is very important for a medical transcriptionist.