PIERCE COLLEGE PUYALLUP
BUSINESS INFORMATION TECHNOLOGY
MEDICAL TRANSCRIPTION I
BTECH 251 SYLLABUS
(5 credits)
PREREQUISITES: BTECH 151 and BTECH 230 with grades of 2.0 or better.
COURSE DESCRIPTION: This is a sequential course involving skills in word processing/machine transcription of
medical records for health care facilities, including transcription of various types of medical reports, formatting of medical
reports and use of medical references.
REQUIRED MATERIALS:
1. Medical Transcription Fundamentals and Practice, Third Edition with CD-ROM by Health Professions Institute,
published by Pearson Prentice Hall, 2007. ISBN-13: 978-0-13-188143-3.
2. One storage device.
3. 3-ring binder with A-Z guides.
4. 6 Scantrons.
RECOMMENDED MATERIALS:
(Copies available for use in the Business Information Technology Lab)
1.
2.
3.
4.
5.
6.
Medical Typing & Transcribing, by Fordney and Diehl, published by W. B. Saunders.
Medical dictionary, Dorland’s or Taber’s recommended, and an English dictionary.
Drug reference (P.D.R., Billups, Drake and Drake, or other).
Medical Word Book (Saunders) with tab indexing by student.
Surgical Word Book (Saunders).
Anatomy and physiology text (Gray’s Anatomy or other).
STUDENT OUTCOMES:
Upon completion of the course, the student will be able to do the following:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Operate a transcribing machine efficiently with intermittent listening and continuous keying.
Use, understand, and correctly spell the medical terms as they are transcribed.
Define the six categories of transcription errors and how to avoid or minimize them.
Punctuate and express numbers properly in medical documents.
Use a medical dictionary and medical references.
Format medical documents in an acceptable format as instructed.
Follow proper procedures for producing, preparing, and assembling medical documents for each type of citation
transcribed.
Transcribe dictation from each medical specialty.
Produce final copy from the transcriber in as short a time as possible.
Proofread medical documents for content, spelling, punctuation, and form.
Describe the purpose and content of each type of medical report.
Cite the reasons why medical transcriptionists must uphold high ethical standards.
Produce a concise report on an AAMT meeting or a medical condition of interest.
BTECH 251
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14. Evaluate the impact of personal attendance and meeting deadlines.
RELEASE OF ACADEMIC INFORMATION:
Any student whose education is being sponsored by an agency that may require reports concerning class progress is
asked to sign a Release of Information form by the 10th day of class. Please see your instructor as soon as possible.
OVERALL GRADING:
Textbook exercises
Graded transcribed reports
Ungraded transcribed reports
Terminology Tests
Transcription Tests
Notebook
Report/Professional Org. Meeting
10% of final grade
20% of final grade
20% of final grade
15% of final grade
15% of final grade
10% of final grade
10% of final grade
GRADING PROCEDURES:
Textbook Exercises
The Proofreading Skills and Skills Challenge should be completed for each chapter and should be checked by the
students against the Student Answer Key.
4.0
.25 to 4.0 deduction
Exercises are complete, carefully checked by student, errors noted at top of exercise,
and assignment labeled correctly.
if one or more of the above instructions is not followed. Assignments that are not in the
correct order or not labeled may be handed back to the student ungraded.
Graded Transcribed Reports
Transcription will be evaluated for correct spelling of medical terminology, medications, punctuation, grammar, and
format. Student transcription may not agree with the Key but may still be correct. In medical transcription, different is
not always wrong.
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A maximum grade of 4.0 is possible for each report.
See Error Analysis Chart for deductions.
Two question marks (?) are permitted per report and test with no point deduction.
ERROR ANALYSIS CHART
Major Errors (-.5 pt.)
Grave Error
Serious Error
Missing word(s)
Major misspelling
Wrong word(s)
Medication error
Minor Errors (-.25 pt.)
Significant
Less Serious
Typo error
Grammar error
No Deduction
Insignificant
Format error
Punctuation
error
Format or punct.
error that affects
the meaning
Diagnosis error
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Ungraded Transcribed Reports
These reports will be spot checked by the instructor. For every error that is not found by the student, the following
grading procedure will be implemented:
0-4 errors
5-8 errors
9-12 errors
13-16 errors
= 4.0
= 3.5
= 3.0
= 2.5
17-20 errors
21-24 errors
25-28 errors
29 + errors
= 2.0
= 1.5
= 1.0
= 0.0
Terminology Tests
Students will take 6 terminology tests. These tests are comprised of 20 matching questions on the chapter terms. A
Scantron is needed for these tests. The percentage of correct answers will be converted to a 4.0 scale. All tests are
closed book and no notes.
Transcription Tests
Student will take 6 transcription examinations. Each test will be transcription of a new report and must be typed final
copy only (no rough drafts). These transcription tests will be graded the same as the graded transcription reports. You
may use all references including the Medical Transcription Fundaments & Practice text. These include a medical
dictionary, typed key terms, drug references, Medical or Surgical Word Books, or the Anatomy and Physiology text.
Notebook
Student will prepare a transcriptionist’s notebook with notes/entries from daily transcription, assignments, or discussion
with the instructor. These entries can be any kind of information that the student might want to access quickly during
future transcription. This will be evaluated at the end of the course.
4.0
.25 to 4.0 deduction
Notebook appears to have been maintained in an orderly manner throughout the quarter and
would likely be useful to the student in the future.
Notebook is missing some or all of the above or has incorrect information.
Report/Professional Organization Meeting
Student will prepare a report on a medical condition of interest to them (one page, single spaced)
OR
Student will attend one meeting of the Rainier Chapter of the American Association for Medical Transcription (AAMT) or
equivalent, or other professional meeting approved by instructor. Students will submit a brief written report of the
speaker and the meeting and will seek out one member and report that person’s name and work place.
TEXT AND TRANSCRIPTION REPORTS
The Medical Transcription text is designed for use with the assigned transcription reports. These medical reports are
available on the CD –ROM that is included with your book. Loading instructions for the program are located in the file
titled readme.txt on the CD. If you have a digital foot pedal, you may do your transcription at home. The program will
be loaded on some of the computers along with the digital foot pedals in the BTECH Lab as well.
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A word list accompanies each chapter as well as a Quick Reference Word List that starts on page 521 in the back of the
book. The word list certainly does not have all of the words that will be used on the reports so you may need to use
other reference materials such as those listed on the first page under Recommended Materials.
The reports are actual physician dictation from all specialties and will be used in both Med. Transcription I & II.
ASSIGNMENT SCHEDULE – BTECH 251
WEEK 1
Read Chapters 1 & 2
Read Chapter 3
Complete Textbook Exercises for each chapter.
Complete Textbook Exercises.
Chapter 3, Style Guide, provides reference material that the student should consult for word usage, style of
report, grammar, and punctuation. Know this chapter well.
Read Chapter 4 – Dermatology
Transcribe Chapter 4 Reports (4 reports)
Complete Textbook Exercises
Reports 1, 2, 4, & 6 (#4 is graded)
Transcription Reports: Students should transcribe reports trying to achieve high-quality originals (first draft)
transcription with correct spelling, punctuation, grammar, and formatting. Even if the report gives a patient’s
name, do not use the patient’s name in the report. Replace the name with “the patient”.
Before beginning, please review the information about the graded/ungraded transcribed reports, the ERROR
ANALYSIS CHART, the Report Format and the Model Report on pages 5 & 6, and the Helpful Hints that start right
after the Model Report.
Each ungraded report should be checked by the student using the Student Answer Key in the BTECH Lab. Please
circle the errors found, and note the number of errors at the top of the page. If no errors are found, please
indicate that at the top of the page. If the student does not proof the reports, the assignments may be handed
back to the student ungraded with instructions to proof the reports. Do not retype the reports until they are
perfect. These reports are practice.
Carefully check your graded reports. There will be no report with which to compare your report in the Student
Answer Key. Two question marks are allowed per report. This indicates that after checking all possible
references, you are still not completely sure of the correct spelling of the word.
Turn in one complete chapter’s transcribed reports, stapled in order, with this heading on the first page:
Student’s Name
BTECH 251
Chapter Number
Instructor’s Name
Date
WEEK 2
Terminology Test
Transcription Test
Read Chapter 5-Otorhinolaryngology
Transcribe Chapter 5 Reports (4 Reports)
Chapter 4 – Dermatology
See Instructor
Complete Exercises
Reports 1, 2, 5, & 9 (#2 is graded)
WEEK 3
Continue on Chapter 5 transcription
Terminology Test
Chapter 5 – Otorhinolaryngology
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Transcription Test
See Instructor
WEEK 4
Read Chapter 6 – Ophthalmology
Transcribe Chapter 6 Reports (3 Reports)
Terminology Test
Transcription Test
Complete Exercises
Reports 1, 2, & 4 (#4 is graded)
Chapter 6 – Ophthalmology
See Instructor
WEEK 5
Read Chapter 7 – Pulmonary Medicine
Transcribe Chapter 7 Reports (5 Reports)
Complete Exercises
Reports 1, 2, 4, 7, & 8 (#8 is graded)
MID-QUARTER DEADLINE_______________________________
All assignments through Week 5 are to be completed by this date.
WEEK 6
Terminology Test
Transcription Test
Read Chapter 8 – Cardiology/Hematology
Chapter 7 – Pulmonary Medicine
See Instructor
Complete Exercises
WEEK 7
Transcribe Chapter 8 Reports (7 Reports)
Reports 1, 4, 8, 12, 13, 18, & 19 (#8 is graded)
WEEK 8
Terminology Test
Transcription Test
Chapter 8 – Cardiology/Hematology
See Instructor
WEEK 9
Read Chapter 9 – Gastroenterology
Transcribe Chapter 9 Reports (5 Reports)
Report Due
Complete Exercises
(Reports 1, 3, 6, 7, & 9 (#9 is graded)
WEEK 10
Terminology Test
Transcription Test
Notebook Due
Chapter 9 – Gastroenterology
See Instructor
REPORT FORMAT
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Block format—everything begins at the left margin.
Physician signature block, transcriptionist’s initials, and date of transcription at bottom indicate completeness.
Student name, class, date, assignment identification are to be placed on upper right corner of every group of
assignments.
Single spaced with double spaces between paragraphs.
Approximately 1” margins (may be changed to make report fit on the page).
Page 2 should have information on it to easily connect it to page 1.
See Model Report next page.
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MODEL REPORT
Student’s Name
BTECH 251
Chapter #, Report #
Instructor’s Name
Date
DISCHARGE SUMMARY
HISTORY: This 43-year-old male was admitted for intractable neck and right arm pain of a
radicular nature. He had a cervical myelogram. Findings on myelography were a sharp
extradural defect at the C5-6 level with deformation of the nerve root and narrowed foramina.
The patient will be discharged and think about recommendations. Spinal fluid glucose was 68
with protein 57.
FINAL DIAGNOSIS: Degenerative cervical disk disease with radiculopathy at C5-6.
OPERATIONS: None.
CONDITION: Unchanged.
PROGNOSIS: Uncertain.
DISCHARGE INSTRUCTIONS: If he has any problems, he should contact me by phone.
Otherwise, a routine appointment will be given in the next 1-2 weeks.
Physician
nr/11-25/09
Helpful Hints for Medical Transcriptionists
Earphones must be comfortable and clean o be useful.
To become employed: All employers will give a tape test – A tape unfamiliar to the applicant that must be
transcribed accurately. References are usually permitted. Rough track will be kept of the time required to
complete the report or a time limited will be given. Written tests may also be given on medical terminology
and English grammar/spelling as well as a timed typing test.
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The industry standard for medical transcription is:
10 minutes of dictation completed in an hour or
100 + lines
completed in an hour or
1000 + words
completed in an hour.
Word, line, and character counts are available in both WordPerfect and MS Word.
The first medical transcription reports a student does will be extremely difficult to do, because this is a totally
new kind of activity for the student. Therefore, do not be anxious about your speed. It will improve with each
report but very slowly. You may want to keep a time log of how long it takes you to do each report (as well as
the number of lines, words, etc.) and track your progress from report to report. Remember that although
medical transcription is slow and difficult for you to do now, the reason you are in class is to learn how to do
it. The best place to make your errors is in class, not on the job. Medical transcription is always a group effort.
A transcriptionist's notebook can be your best reference tool. This should be a loose-leaf notebook, divided
alphabetically with tab-indexes. In this, keep track of every word that it was ever necessary for you to look up,
also miscellaneous samples, lists, new medications, words, etc.
The act of entering the word will sometimes fix it permanently in your mind. Also, it is sometimes necessary
to look up the same words every time because they will not "stick." Sometimes your notebook will be the only
place to find new terms that have been gleaned from reading or on-the-job experience. Hand-outs and
especially samples of types of transcription (e.g. school assignments) can also be placed in your own
notebook. It should be a repository for anything that can be of help on the job.
The text key has discrepancies. When checking your work against it, not everything that is different is an
error. The key tries to make the transcripts "perfect," but they should be only "improved." It often has
headings where none were dictated or paragraphs where none are needed.
Do transcribe exactly as dictated: Do not edit, add or subtract, except to change errors in grammar,
sometimes in terminology, plurals, etc.
Each work place has its own rules about abbreviations, capitalization, commas, productivity, etc. Often, there
will not be a choice about format, because the facility's computer system will determine placement of
information.
Types of Medical Transcription:
History & Physical
Discharge Summary
Consultation
Operative Report
Short-Stay Record
Minutes of Meetings
Chromosome Analysis
X-Ray
EEG Report
EKG Report
Manuscript
Clinic Visit
Forms (many types)
Laboratory Report
Letters/Memos
Emergency Room Note
Pathology Report (surg. specimen)
Pathology Report (autopsy)
Progress Note
Chart Note/S.O.A.P. (POMR) note
Curriculum Vitae (doctor's resume)
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.
Spell check is wonderful, but it will not take care of everything. It does not know the difference between "their,"
"they're," or "there." It does not know plurals or most proper names (especially medications, except the simplest,
e.g., aspirin, penicillin, etc.). Never trust a doctor’s spelling, ever, anywhere. Never rely on Spell Check, ever,
anywhere.
Never guess at anything. A blank is an honorable thing. It means you don’t know. If you have a discrepancy in
your dictation, flag it for the manager’s attention.
**Work must be turned in by November 30th. We will
not be accepting work after this date.**
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