Hillcrest Medical Center: Beginning Medical Transcription , Seventh Edition

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 & 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. Cover Page......Page 1 Title Page......Page 4 Copyright Page......Page 6 CONTENTS......Page 8 NEW TO THIS EDITION—FEATURED ITEMS......Page 14 COURSE DESCRIPTION......Page 15 OBJECTIVES......Page 16 STUDENT TEXT-WORKBOOK......Page 17 SUPPLEMENTS......Page 18 ABOUT THE AUTHORS......Page 19 HOW TO STUDYWARETM......Page 20 SUPPLEMENTS AT A GLANCE......Page 23 SECTION 1: Introduction......Page 25 Welcome to Hillcrest Medical Center......Page 26 Legal Issues......Page 27 Length of Course......Page 28 Evaluations......Page 29 Appendix......Page 30 Certification/Credentialing......Page 31 Medical Transcriptionist Job Descriptions: Results of a Benchmarking Analysis of MT Professional Levels......Page 32 Code of Ethics......Page 34 Health Insurance Portability and Accountability Act (HIPAA)......Page 35 Recredentialing......Page 36 Employment Possibilities......Page 37 History and Physical Examination (H&P)......Page 38 Discharge Summary......Page 39 Outpatient Reports......Page 40 SECTION 2: Model Report Forms......Page 41 Model Report Form 1 History and Physical Examination or Emergency Department Treatment Record......Page 42 Model Report Form 2 Radiology Report or Diagnostic Imaging Report......Page 44 Model Report Form 3 Operative Report......Page 45 Model Report Form 4 Pathology Report......Page 47 Model Report Form 5 Consultation......Page 48 Model Report Form 6 Discharge Summary......Page 50 Model Report Form 7 Death Summary......Page 52 Model Report Form 8 History, Physical, Impression, Plan (HPIP)......Page 54 Model Report Form 9 Subjective, Objective, Assessment, Plan (SOAP)......Page 55 Model Report Form 10 Correspondence......Page 56 SECTION 3: References......Page 59 Style Variations......Page 60 Capitalization......Page 61 Numbers......Page 62 Punctuation......Page 64 Abbreviations and Symbols......Page 65 The Grammar of Microbiology......Page 67 Vital Signs......Page 68 Race/Age......Page 69 Subjective versus Objective......Page 70 The ABO Blood Group......Page 71 Jr, Sr, II, and III......Page 72 Report Formatting Guidelines......Page 73 Speech Recognition Technology......Page 74 Principles......Page 75 Prefixes, Pronunciation......Page 76 Combining Forms......Page 78 Suffixes......Page 82 Doctors’ and Other Professional Names Used in Hillcrest and Quali-Care Clinic......Page 84 Skill-Building Report Log......Page 85 SECTION 4: Case Studies......Page 87 Case Study 1: Reproductive System......Page 88 Case Study 2: Gastrointestinal System......Page 94 Case Study 3: Cardiopulmonary System......Page 99 Case Study 4: Integumentary System......Page 105 Case Study 5: Psychology/Neurology System......Page 109 Case Study 6: Nervous System......Page 113 Case Study 7: Orthopedics/Endocrine Systems......Page 120 Case Study 8: Vascular/Renal Systems......Page 124 Case Study 9: Musculoskeletal System......Page 129 Case Study 10: Respiratory System......Page 133 SECTION 5: Quali-Care Clinic......Page 137 Welcome to Quali-Care Clinic......Page 138 Quali-Care Clinic Outpatient Report Log......Page 139 Outpatient Reports......Page 140 SECTION 6: Expand Your Knowledge......Page 199 Crossword Puzzle—Case 1 Glossary......Page 200 Crossword Puzzle—Case 2 Glossary......Page 202 Crossword Puzzle—Case 3 Glossary......Page 204 Crossword Puzzle—Case 4 Glossary......Page 206 Crossword Puzzle—Case 5 Glossary......Page 208 Crossword Puzzle—Case 6 Glossary......Page 209 Crossword Puzzle—Case 7 Glossary......Page 211 Crossword Puzzle—Case 8 Glossary......Page 213 Crossword Puzzle—Case 9 Glossary......Page 215 Crossword Puzzle—Case 10 Glossary......Page 217 Crossword Puzzle—Quali-Care Glossaries 1–4......Page 219 Crossword Puzzle—Quali-Care Glossaries 5–9......Page 221 Crossword Puzzle—Quali-Care Glossaries 10–12......Page 223 Crossword Puzzle—Quali-Care Glossaries 13–17......Page 225 Crossword Puzzle—Quali-Care Glossaries 18–21......Page 227 Crossword Puzzle—Quali-Care Glossaries 22–25......Page 229 Crossword Puzzle—Prefixes, Suffixes, and Combining Forms......Page 231 Proofreading Exercise 1......Page 232 Proofreading Exercise 2......Page 233 Proofreading Exercise 3......Page 235 Proofreading Exercise 4......Page 237 Proofreading Exercise 5......Page 239 Proofreading Exercise 6......Page 241 Proofreading Exercise 7......Page 242 Proofreading Exercise 8......Page 244 Proofreading Exercise 9......Page 246 Proofreading Exercise 10......Page 248 Proofreading Exercise 11......Page 250 Proofreading Exercise 12......Page 252 Common Dictation Errors......Page 255 APPENDIX......Page 257 Proofreader’s Marks......Page 258 Challenging Medical Words, Phrases, Prefixes......Page 259 Sample Patient History Form......Page 265 The Lund-Browder Chart......Page 267 Urinalysis (UA)......Page 268 Chemistry Profile (Chem Profile)......Page 269 Sample Forms For Ordering Laboratory Tests, Scheduling Radiology Tests, And Consults For Physical Therapy, Sleep Studies, Etc.......Page 271 Building A Reference Library......Page 279 A Healthcare Controlled Vocabulary......Page 280 Official “Do Not Use” List From The Joint Commission......Page 284 BIBLIOGRAPHY......Page 285 INDEX......Page 287