Proper English usage in Medical Transcription

It has been observed that most of the errors in a document are due to English usage. To overcome this issue please remember the following:

1. On dates use only commas with the month, day, and year expressed. You do not need commas with partial dates:
On February 1 the patient was seen.
In February 2002 the patient was seen.
On February 1, 2002, the patient was seen.

2. If mixed numbers in same sentence, make them all the same; use majority rules:

The patient had 2 brothers, 15 cousins, 14 uncles, and 4 aunts.
If numbers are over 11 and using numerals, then use numerals for everything. You can’t say: The patient will return in six to 12 months. It’s either 6 to 12 months or six to twelve months.

3. Use semicolons to separate items which contain commas:
Example: The patient was seen June 1; February 4; August 3, 2000; January 2, 2001; and February 5, 2001. (Items contain their own commas and need to be separated with a semicolon.) Or: Records were received from Seton Medical Center; San Francisco General Hospital; Tali Bashour, M.D.; Patty Pierce, Esq.; and James Pertsch, M.D. (commas within commas)

4. Do not hyphenate with pre, post, re, inter, intra, sub, etc. Might want to check BOS or Medical Transc. Do’s and Don’ts for complete list.

5. Hyphenate combined adjectives if they come before the noun:

Low-grade fever, air-contrast barium enema, two-month history, 1-mm sebaceous cyst, or 1-cm nodule.

6. A suspended hyphen is:
The patient has a two- to three-year history of… Also can type 1x1-mm node or 1- x 1-mm node
Do not type two-to-three-year history.

7. You only need a comma in an opening phrase containing more than five words or a verb.

Example: When the patient was last seen, he . . . (contains verb + more than five words).

In January 2003 while in San Francisco, he visited his uncle.

On examination (no comma needed) the patient had right leg pain.

8. Use commas after three-syllable intro words, such as additionally, however, therefore, furthermore, etc., to start a sentence.

9. Use semicolons if you connect two complete sentences with however, therefore, furthermore, etc., and use a comma after the connecting word.
Example: The patient was told to return in one week; however, he never came to the appointment.

10. Do not use periods with licensure abbreviations: RN, LVN, PA-C, etc.

11. Use periods with degrees: M.D., Ph.D, D.O., D.D.S, D.P.M., etc.

12. Periods and commas ALWAYS go inside quotes. Semicolons and colons go OUTSIDE quotes.

13. Place commas around nonessential words or clauses within a sentence. Example: In fact, e.g., i.e., etc., Sentence example: absent any injury, etc.

14. Use an apostrophe to show possession of singular nouns that end in s or in a strong s sound.
Example: the waitress’ table, for appearance’ sake, Dr. Moses’ appointment, and
Mr. Gomez’ surgery (incorrect: Mr. Gomez’s surgery.)

15. Followup - noun. He will return for followup.
Follow-up - adjective. He will return for a follow-up visit.
Follow up - verb. He will follow up here.

16. Can be November 14 or 14th of November, but not November 14th.

17. Patient saw her primary care physician Dr. Roost.
OR: The patient saw Dr. Roost, her primary care physician.
(Incorrect: Patient saw her primary care physician, Dr. Roost.)

18. The patient does not use tobacco products but does use alcohol products. (no comma before but).

The patient does not use tobacco products, but he does use alcohol products. (comma needed.)

Does Pune still claim to be "Pensioner's Paradise"?

Pune has always been considered as a "Pensioner's Paradise". But with the recent bomb blast in the German Bakery in Koregaon Park, it certainly raises the question if it really still remains a Pensioner's paradise.

Though the incident was cowardly act by the terrorist it was good to find that the victims got medical help very quickly with the nearby citizens coming to the rescue. Thanks and hats off to their help and effort and the presence of mind shown to provide immediate help to the victims and injured. The media though, made a show out of it with questions and remarks like idiots. Aren't they going to ever grow and behave like mature, responsible people?

But certainly it is going to affect the sense of safety in the minds of the citizens of Pune for a long time to come.

May God give the families of the deceased and injured the courage to go through this difficult time.

DIFFERENCE BETWEEN FOCUSING ON PROBLEMS AND FOCUSING ON SOLUTIONS

CASE 1

When NASA began the launch of astronauts into space, they found out that the pens wouldn't work at zero gravity (ink won't flow down to the writing surface).
They developed a pen that worked at zero gravity, upside down, underwater, in practically any surface including crystal and in a temperature range from below freezing to over 300 degrees C. To solve this problem, it took them one decade and $12 million.

And what did the Russians do...??
They used a pencil.

CASE 2

One of the most memorable case studies on Japanese management was the case of the empty soapbox, which happened in one of Japan's biggest cosmetics companies. The company received a complaint that a consumer had bought a soapbox that was empty. Immediately the authorities isolated the problem to the assembly line, which transported all the packaged boxes of soap to the delivery department. For some reason, one soapbox went through the assembly line empty. Management asked its engineers to solve the problem. Post-haste, the engineers worked hard to devise an X-ray machine with high-resolution monitors manned by two people to watch all the soapboxes that passed through the line to make sure they were not empty. No doubt, they worked hard and they worked fast but they spent a whooping amount to do so.

But when a rank-and-file employee in a small company was posed with the same problem, he did not get into complications of X-rays, etc., but instead came out with another solution. He bought a strong industrial electric fan and pointed it at the assembly line. He switched the fan on, and as each soapbox passed the fan, it simply blew the empty boxes out of the line.

Moral: Always look for simple solutions. Devise the simplest possible solution that solves the problems. Always focus on solutions & not on problems. So the end of the day the thing that really matters is

HOW ONE LOOKS AT THE PROBLEM and Resolves it early

You thought this happens only in India?

Human error, though no room for errors in the Medical field and hence not acceptable.

Training Institutes is the need of the day

There is an urgent need of good training institutes for Medical Transcription in Pune. As an owner of a MT unit myself, get number of phone calls asking where training is available. Work coming in Pune is steadily increasing and there is lack of skilled man power. Maybe it is high time for Educational institutions to conduct courses in medical transcription. I think medical colleges should think of doing so since they already have the staff to teach anatomy / physiology / pharmacology and can thus design a course which will be affordable to those interested in this field.

Humor In MT

DOCTORS' NOTES ON PATIENT CHARTS (ACTUAL NOTES--UNEDITED)

1. Patient has chest pain if she lies on her left side for over a year.
2. On the 2nd day the knee was better and on the 3rd day it disappeared completely.
3. She has had no rigors or shaking chills, but her husband states she was very hot in bed last night.
4. The patient has been depressed ever since she began seeing me in 1997.
5. The patient is tearful and crying constantly. She also appears to be depressed.
6. Discharge status: Alive but without permission.
7. Healthy appearing decrepit 69 year-old male, mentally alert but forgetful.
8. The patient refused an autopsy.
9. The patient has no past history of suicides.
10. Patient has left his white blood cells at another hospital.
11. Patient's past medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.
12. Patient had waffles for breakfast and anorexia for lunch.
13. Between you and me, we ought to be able to get this lady pregnant.
14. Since she can't get pregnant with her husband, I thought you might like to work her up.
15. She is numb from her toes down.
16. While in the ER, she was examined, X-rated and sent home.
17. The skin was moist and dry.
18. Occasional, constant, infrequent headaches.
19. Patient was alert and unresponsive.
20. Rectal exam revealed a normal size thyroid.
21. She stated that she had been constipated for most of her life, until she got a divorce.
22. I saw your patient today, who is still under our car for physical therapy.
23. Both breasts are equal and reactive to light and accommodation.
24. Exam of genitalia reveals that he is circus sized.
25. The lab test indicated abnormal lover function.
26. The patient was to have a bowel resection. However, he took a job as a lawyer instead.
27. Skin: Somewhat pale but present.
28. The pelvic examination will be done later on the floor.
29. Patient was seen in consultation by Dr. Blank, who felt we should sit on the abdomen and I agree.
30. Patient has two teenage children, but no other abnormalities.

Hi Folks

This is just the beginning. I don't know right now from where to proceed. So I guess I should sleep over it tonight and come up with some thing to write here.