MR250 MEDICAL TRANSCRIPTION I Week 1 Instructor: Amber Krasny MBA, CPC, CMRS

Introduction! – Self-introduction. – Please post a nice introduction of yourself in the classroom DB. – Please read each others introductions and post a comment to at least two of your classmates.

Question #1 What are you most nervous about in this class?

Syllabus Review – Do you have any questions about the Syllabus? – Have you all received your 3 textbooks? Medical Transcription Fundamentals, Gilmore The Book of Style for MT, 3 rd Edition Stedman’s Pocket Medical Dictionary – Download AIM for our office hours meeting place?

Syllabus Review Cont. Do you all have your foot pedal and software? Go to to install the software for the transcribing and to down load the Student Manual. You MUST get that up and running this week because we use it starting right off in Week 2

How to use the textbooks… Complete all the readings as assigned in your class. In Gilmore textbook: –Complete the Skills Quick Check exercises. –Complete the Review Questions. –Complete the Chapter Activities.

PowerPoint Slides Did You Know... –The PowerPoint slides for each weeks Seminar will be in the Doc Sharing area? –Please review them before class. –Answer the questions while you are reading, so you will be prepared for the Seminar!

Questions from Gilmore…pp What is a transcriber? List 3 important features of the transcriber. Why do we need a head set?

Questions from Gilmore Cont. What is the foot pedal? Which of the things below can be done with the foot pedal: 1.Playback the dictation 2.Erase the dictation 3.Rewind the dictation 4.Fast forward the dictation 5.Identify misspelled words.

ANSWER KEY 1.Playback the dictation 2.Rewind the dictation 3.Fast forward the dictation

WORDDEFINITIONS A. Speech-Recognition Technology B. Medical spell checker C. Template D. Macros E. AutoCorrect F. AutoText 1. Provides suggestions for spelling 2. interpret human speech, word for word 3. Stores and quickly inserts items used frequently in a document. 4. A sequence of events recorded to play back later 5. Automatically corrects common mistakes as they are typed. 6. A document with preset formatting and settings

WORDDEFINITION A. Speech-Recognition Technology (2) B. Medical spell checker (1) C. Template (6) D. Macros (4) E. AutoCorrect (5) F. AutoText (3) 1. Provides suggestions for spelling (B) 2. interpret human speech, word for word (A) 3. Stores and quickly inserts items used frequently in a document. (F) 4. A sequence of events recorded to play back later (D) 5. Automatically corrects common mistakes as they are typed. (E) 6. A document with preset formatting and settings (C)

Chapter 4: Medical Correspondence and Reports…QUESTIONS… 1.What is the purpose of the medical record? 2.What are the three basic elements of a medical document? 3.List the main reports that you will be transcribing? 4.What is a SOAP Note and what do the letters stand for?

ANSWER KEY 1.To ensure the patients are adequately informed about their treatment options, or to ensure that the information regarding a patient’s history is complete and is readily available to any practitioner involved in the patient’s care. 2.Page Numbering, Headings, and Text. 3.Clinic note/Chart Note, History & Physical, Operative Report, Consultation Report, Progress Note, Discharge Summary.

ANSWER KEY Cont. 1.SOAP Note: 1.A clinic note using the SOAP format indicates the headings. 1.S=Subjective 2.O=Objective 3.A=Assessment and 4.P=Plan

The Book of Style pages 3-22 QUESTIONS… 1.What is the first document in the chronology or reports? 2.What does ASTM’s E2184 Standard Specification for Healthcare Document Formats call for you to do when transcribing? 3.What three things will you type at the bottom of each report? 4.What are the Acute Care TATs? 5.What are the Outpatient TATs?

ANSWER KEY 1.History & Physical ASTM’s E2184 requires for all major headings in the report as well as allergies to be expressed in all capital letters but with regular type (not bold) Signature Block 1.2.7, Dictator/Transcriptionist Initials 1.2.8, Time/Date Stamping Within no more than 24 hours of admission (1.3.1): H&P, Nursing Assessment, Nutritional Screening, Functional Status Screening.

ANSWER KEY Cont. 5. In general, a hour turn- around time expectation prevails in most of the private sector for transcription. There is often a 24-hour-or-less TAT expectation for unique reports—such as new pt. H&Ps, consultation letters, notifications to insurance companies, and other documents considered of high priority.

The End… Well that’s all for today! Thanks for joining us. I hope you learned something to help you in your new transcription career! Don’t forget to get TMS-MT Client up and running this Week! And get all of your assignments in on time! See you next week! Same time— same place