Synopses & Reviews
HILLCREST MEDICAL CENTER: BEGINNING MEDICAL TRANSCRIPTION, 7th Ed. creates a simulation approach to medical transcription that will give readers a working knowledge of the medical reports most commonly used in both inpatient and outpatient care settings. Readers will transcribe over 100 real medical reports including 10 comprehensive inpatient case studies and 25 outpatient clinic records. HILLCREST MEDICAL CENTER BEGINNING MEDICAL TRANSCRIPTION, 7th Ed. is organized by body system and includes full color anatomy and physiology illustrations and coverage of medical terminology. In addition, HILLCREST MEDICAL CENTER BEGINNING MEDICAL TRANSCRIPTION, 7th Ed. provides a review of proper formatting, grammar, and style in accordance with the AHDI's Book of Style. Transcribed reports include: history and physical examinations; consults; operative, pathology, and radiology reports; SOAP notes; and death and discharge summaries.
This best-selling transcription book is now printed in full color, enhancing the anatomical illustrations presented. The book and practice software create a simulation approach, giving learners a working knowledge of the medical reports most commonly used in hospital and ambulatory care settings. Learners transcribe a variety of reports from inpatient case studies taken from actual medical reports. Organized by body system, reports transcribed include history and physical examination, operative, pathology, radiology, and discharge summary.
About the Author
Patricia A. Ireland, CMT, AHDI-F, has worked as a medical transcriptionist since 1968 and has been an instructor of medical terminology and medical transcription for over thirty years--teaching in house and now on line since 2000. A certified medical transcriptionist since 1981, Ms. Ireland has worked in various settings, including hospitals, clinics, and doctor's offices, as well as two years overseas in Riyadh, Saudi Arabia plus 1-1/2 years in Kingston, Jamaica. Ms. Ireland currently lives in San Antonio, Texas, with her cats where she is a part-time instructor for the on-line division of Mildred Elley. She is an active member of her professional association, the Association for Healthcare Documentation Integrity (AHDI) as well as the Capital Chapter of AHDI in Austin. Ms. Stein has been a medical transcriptionist for almost 31 years, having begun my career in 1977 at a multispecialty worldwide referral medical center in Galveston, Texas. She became a Certified Medical Transcriptionist in 1981. Most of her experience has been transcribing reports in the acute-care hospital setting. She is currently a part-time medical transcription specialist at the Methodist Healthcare System in San Antonio, Texas, and teaches an online medical transcription course for Gatlin Education Services.
Table of Contents
Preface. Prerequisites. New to this Edition with Featured Items. Course Description. Objectives. Student Text-Workbook. Instructor's Manual. About the Authors. Supplements at a Glance. How to Use StudyWARE™. SECTION 1 INTRODUCTION. Welcome to Hillcrest Medical Center. Confidentiality Policy. Legal Issues. Objectives. Length of Course. Certification. Transcribing Medical Reports. Evaluations. Expand Your Knowledge: Word Games and Exercises. Listing of Appendix. Association for Healthcare Documentation Integrity. Medical Transcriptionist Job Descriptions. AHDI Code of Ethics. Certification Possibilities--RMT and CMT. Health Insurance Portability and Accountability Act: MT checklist. Understanding Medical Records. History and Physical Examination (H&P). Diagnostic Imaging or Radiology Report Operative Report (OP). Pathology Report (Path). Consultation (Consult). Discharge Summary. Death Summary. Autopsy Report. Outpatient Model Reports. SECTION 2 MODEL REPORT FORMS. SECTION 3 REFERENCES. Transcription Rules for Hillcrest Medical Center and Quali-Care Clinic. Style Variations. Capitalization. Numbers. Punctuation. Abbreviations and Symbols. List of Metric Measurements. The Grammar of Microbiology. Vital Signs. CMTips™. Difficult Singular and Plural Words and Phrases. Temperature versus Fever. A Tongue Twister. Dermatology Terms. Pulmonary Terms. Race/Age. Zero Safety. The Digits. Time. Abduction versus Adduction. Class and Stage. Connective Tissues. Subjective versus Objective. Surgical Terms. Obstetric Terms. Cardiology Terms. The ABO Blood Group. Jr, Sr, II, and III. Report Formatting Guidelines. The Future of Medical Transcription. Skill-Building Report Log. Doctors' and Other Professional Names Used. Understanding Medical Terminology. Principles. Prefixes/Pronunciation. Combining Forms. Suffixes. SECTION 4 CASE STUDIES. Case 1 The Reproductive System. Glossary. Case 2 The Gastrointestinal System. Glossary. Case 3 The Cardiopulmonary System. Glossary. Case 4 The Integumentary System. Glossary. Case 5 The Psychology Neurology System. Glossary. Case 6 The Nervous System. Glossary. Case 7 The Orthopedics/Endocrinology System. Glossary. Case 8 The Vascular/Renal System. Glossary. Case 9 The Musculoskeletal System. Glossary. Case 10 The Respiratory System. Glossary. SECTION 5 QUALI-CARE CLINIC. Welcome to Quali-Care Clinic. Quali-Care Clinic Outpatient Report Log. Outpatient Reports. Report 1a&b Consult and Echocardiogram (Cardiology). Report 2 Operative Procedure (Genitourinary). Report 3 Operative Report (Orthopedics). Report 4 Surgical Pathology Report (Breast). Report 5 Emergency Dept Treatment Record (Pediatrics). Report 6 Interventional Radiology (Vascular). Report 7 Spine Clinic HPIP Note (Orthopedics). Report 8 Radiology Report (Orthopedics). Report 9 Clinic SOAP Note (Vascular). Report 10 Surgical Procedure (Orthopedics). Report 11 Operative Report (Plastic Surgery). Report 12 Colonoscopy Procedure (Gastroenterology). Report 13 Clinic HPIP Note (Internal Medicine). Report 14 Operative Report (Neurosurgery). Report 15 Operative Report (Urology). Report 16 Radiology Report (Orthopedic/Neurology). Report 17 Clinic Followup Note (Pediatric Neurology). Report 18 Operative Report (Obstetrics). Report 19 Operative Report (Orthopedics). Report 20 Clinic Followup Note (Vascular). Report 21 Operative Report (Dentistry). Report 22 Operative Report (Orthopedics). Report 23 Consult (Orthopedics). Report 24 Psychological Evaluation (Psychology). Report 25a&b Letter and Consult (Cardiology). SECTION 6 EXPAND YOUR KNOWLEDGE. Crossword Puzzles 1 through 17. Proofreading Exercises 1 through 12. Common Dictation Errors. Appendix. Proofreader's Marks. Challenging Medical Words, Phrases, Prefixes. Sample Patient History Form. The Lund Browder Chart. Laboratory Test Information. Sample Forms for Ordering Laboratory Tests, Scheduling Radiology Tests. Physical Therapy Consults, Sleep Studies. Building a Reference Library. Web Sites for Transcriptionist' Professional Association. "A Healthcare Controlled Vocabulary" by Dr. Neil Davis. Official "Do Not Use" List from The Joint Commission. Bibliography. Index.