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Transcription Reference Guide Transcription Reference Guide No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, for any purpose, without the express written permission of Weston Distance Learning, Inc. Copyright © 2017, Weston Distance Learning, Inc. All Rights Reserved. 0100000SP26A-17 Acknowledgments Brenda Blomberg, B.A., CPC Leslie Ballentine, M.S. Deborah Carson, B.F.A. Kelly Brown, B.S., RHDS Jamie Schenkel Design/Layout Sandy Petersen, ElPub Jessica Babb-Raymundo, B.A. Affiliations & Partnerships AHDI Corporate Member Accredited by the Colorado Department of Member of the Distance Education Higher Education Division of Better Business Accrediting Commission Private Occupational Schools Bureau Fort Collins, CO www.westondistancelearning.com Table of Contents Introduction ................................................................................................................................................. 1 Patient, Doctor and Facility List ................................................................................................................ 2 Patients ............................................................................................................................................. 2 Doctors ............................................................................................................................................. 2 Facilities ........................................................................................................................................... 2 Quick-learn Guide ...................................................................................................................................... 3 Abbreviations and Acronyms ........................................................................................................ 3 Numbers and Symbols ................................................................................................................... 4 Capitalization .................................................................................................................................. 5 Periods.............................................................................................................................................. 6 Commas ........................................................................................................................................... 6 Semicolons ....................................................................................................................................... 8 Colons .............................................................................................................................................. 8 Apostrophes ..................................................................................................................................... 9 Hyphens ........................................................................................................................................... 9 Format ............................................................................................................................................ 10 Style ................................................................................................................................................ 11 Format Samples ......................................................................................................................................... 14 Formatting Specifics ..................................................................................................................... 14 Keyboarding Tips ......................................................................................................................... 15 Chart Note ..................................................................................................................................... 16 History and Physical Examination ............................................................................................. 17 Consultation Report ..................................................................................................................... 19 Discharge Summary ..................................................................................................................... 21 Operative Report .......................................................................................................................... 23 Lab Tests—Normal Reference Values ..................................................................................................... 24 Pharmaceutical Abbreviations ................................................................................................................. 25 Dangerous Abbreviations ......................................................................................................................... 26 Metric Units ............................................................................................................................................... 27 Online References ..................................................................................................................................... 28 Plurals and Sound-alike Words ............................................................................................................... 29 Common Combined Forms ..................................................................................................................... 31 Word List .................................................................................................................................................... 32 General Words .............................................................................................................................. 32 Integumentary System ................................................................................................................. 33 Integumentary System Equipment, Procedures, Pharmaceuticals and Tests ....................... 34 Neurological System .................................................................................................................... 34 Neurological System Equipment, Procedures, Pharmaceuticals and Tests .......................... 35 Musculoskeletal System ............................................................................................................... 35 Musculoskeletal System Equipment, Procedures, Pharmaceuticals and Tests ..................... 36 Cardiovascular System ................................................................................................................. 36 Cardiovascular System Equipment, Procedures, Pharmaceuticals and Tests ....................... 37 Immune System ............................................................................................................................ 37 Immune System Equipment, Procedures, Pharmaceuticals and Tests .................................. 38 Respiratory System ....................................................................................................................... 38 Respiratory System Equipment, Procedures, Pharmaceuticals and Tests ............................. 38 Gastrointestinal System ............................................................................................................... 39 Gastrointestinal System Equipment, Procedures, Pharmaceuticals and Tests ..................... 39 Genitourinary System .................................................................................................................. 40 Genitourinary System Equipment, Procedures, Pharmaceuticals and Tests ........................ 40 Reproductive System .................................................................................................................... 41 Reproductive System Equipment, Procedures, Pharmaceuticals and Tests .......................... 41 Endocrine System ......................................................................................................................... 42 Endocrine System Equipment, Procedures, Pharmaceuticals and Tests ............................... 42 Operative Reports ......................................................................................................................... 42 Operative Reports Equipment, Procedures, Pharmaceuticals and Tests .............................. 43 Alphabetized Flashterms .......................................................................................................................... 44 Transcription Reference Guide Introduction The Transcription Reference Guide is a valuable tool as you are learning to transcribe medical reports. It includes samples of the report formats you will be using in this course as well as a list of all the rules you will learn, a list of common laboratory values and other references that will be helpful. In addition, you’ll find a section of Word Lists and Alphabetized Flashterms. The Word List corresponds to the terms in the Audio Exercises for this course. The Word List follows the order of the lessons, so you’ll hear some of the general terms first, followed by the specific system terms. When listening to the Word List, you may notice slight differences in pronunciation. For example, you’ll hear an s on the end of some eponyms, but the s is removed in the transcribed report. Doctors will often dictate the plural form of the eponym, but most facilities elect to delete the plural form (Alzheimer’s versus Alzheimer). Learning
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