ME1750: Week 4 Assignment

Give an example of operative report.

What is the purpose of outpatient and inpatient medical reports?

This assignment helps you apply your knowledge from this week’s module

Are medical records the same as medical reports?

Don't forget about the age old question of What are the four classes of biological molecule?

and readings.

In the healthcare industry, a Medical Transcriptionist (MT) is expected to

transcribe different types of medical records and reports accurately.

Understanding the difference between outpatient and inpatient medical If you want to learn more check out Name some countries with lowest gii?

reports will help MTs identify their purpose in any medical facility.

SOAP

Where do you get medico-legal reports?

Answer the following questions.

1. Compare the SOAP method and the CC/PX/DX/RX format for organizing medical reports.

SOAP Method

CC/PX/DX/RX format

Subjective

Chief complaint

Objective

Physical examination

Assessment

Diagnosis

Plan

. Prescription

We also discuss several other topics like What is the enuma elish?

Preparation of an H&P Report

Answer the following questions.

2. In the following document, several words are missing, as indicated by a blank space. Provide the missing term that corresponds to the appropriate information using the word bank below. We also discuss several other topics like Who is kenneth burke?

If you want to learn more check out Where did the aztecs live?

History 

Chief Complaint​: The patient is a 45-year-old woman who has a chronic problem with her throat. 1

Present Illness​: She states that she has had marked hoarseness and, at times, has seemed to have trouble breathing. She originally came to my office because of an ear problem, but that cleared up.

Past:​ History______________

Allergies​: None

Bleeding History​: ​None

Illness​: Usual childhood diseases with no sequelae. Bronchitis in the past. High

blood_______________ pressure.

Operations​: She had removal of uterine_______________, fibroids by hysterectomy. T&A as an adult. Appendectomy as a child.

Medications_______________ Valium, SSKI, cough syrup, hormones, and “nerve pills” of which she is not sure of the names We also discuss several other topics like In ancient times, sumerian taverns and inns on the roadside became popular due to what?

Family History​: Noncontributory

Review of Systems: ​Essentially unremarkable

Miscellaneous Reports

Choose the best answer.

3. Found on a model H&P form, this phrase— “Hospitalized for epididymitis 10 years ago”—is an example of which piece of critical information:

☐ The complaint that prompted the hospital visit

× The patient’s relevant prior medical history

☐ The patient’s social history

☐ The patient’s family history

4. This phrase— “Orthopedic device is noted transfixing the left femoral neck”—indicates that the doctor must have used roentgen rays. As a result, it was most probably found on a:

☐ H&P

☐ Operative report

× Radiology report

☐ Discharge summary

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5. All of the following pieces of information are likely to be found on an operative report EXCEPT for:

☐ The preoperative diagnosis

☐ The postoperative diagnosis

☐ Any complications that arose

× The reason for the consultation

6. A microscopic diagnosis explaining that a patient has “acute and chronic inflammation and granulation tissue” would most likely appear on which report?

☐ Radiology report

☐ H&P

☐ Consultation

× Pathology report

7. On Model Report Form 5, the patient name is Marty Gibbs. The Requesting Physician’s name is Diane Houston, MD, Pediatrics. The Consultant is Patrick O’Neill, MD, Plastic Surgery. From these

pieces of information, we can tell that:

☐ Marty’s doctor, Dr. O’Neill, could not sufficiently treat Marty himself, so he sent him to Dr. Houston for specialized help.

☐ Marty’s doctor, Dr. Houston, could not sufficiently treat Marty herself, so she sent him to Dr. O’Neill for specialized help.

☐ Mr. Gibbs is requesting help from doctors Houston and O’Neill.

× We cannot tell anything from these pieces of information.

8. What are medical records and medical reports?

× Permanent and legal document that contains information that authenticates evidence of facts and events happening to a patient

☐ Legal documents

☐ Documents containing a list of physician’s notes

☐ Formal and informal notes taken by a nurse practioner

9. When transcribing the MT’s roles is to_________

☐ Transcribe all medical records

× Ensure that physician’s motes are accurate, and that they are presented in a narrative that gives complete details of a patient’s health story

☐ Edit all documents transcribed by past MT’s

☐ Keep formal and informal notes taken by all medical staff secured and stored following all 3

10. the types of visits and patient’s notes consist of:

☐ New patient, established patient and Emergency Department Visit

☐ New patient, established patient and surgical notes

☐ New patient, old patient and established patient

× Established patient, new patient and patient’s history

11. This format is characterized for the use of double spacing:

× Basic Block

☐ Modified Block

☐ Run-On Modified Block

☐ Tabulated Block

12. What is the importance of obtaining the correct family history of a patient?

☐ Helps in the identification of past diseases and prevention of future disorders

× Helps in the identification of genetic disorders, traits, diseases and common circumstances that might lead to concerns or needed treatment

☐ Helps in the selection of treatments and future procedures

13. Using the related letters, match​ the report type with its related description.

ally, specimens removed in surgery are examined, and this report is generated. Must be completed within 24 hours.

Dictated by consulting physician, transcribed, and sent to the attending physician.

(B) operative report

Does not always include a physical examination of body systems, but tends to focus more on the motor skills and abilities. Patients are referred to as clients.

(D) pathology report

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Needed when a patient dies in the hospital or within 24 hours after being discharged. Must be dictated and transcribed with 90 days of the patient’s death to be considered complete. (F) autopsy report

Also called clinical resume or final progress note. It is required for each patient discharged from a hospital. Must be completed within 30 days of patient discharge.

(A) Discharge summary

Typically include the date of procedure, number and type of views, quality of the study, findings, etc.

(C.) Pathology repot

Originate from medical offices and hospitals. Usually involves an accident case or a workers’ compensation case. It is admissible as evidence in a court of law.

(G) medicolegal reports

Needed whenever surgical procedure performed at a hospital, an outpatient surgical center, or a clinic. Dictated immediately after surgery.

(E) consultation report

Reflection

Reflect on what you have learned this week to help you respond to the question below. You may choose to respond in writing or by recording a video!

Do you have a preference when learning about inpatient and outpatient medical reports? State your preference and explain why.

No I don't have a preference when dealing with inpatient and outpatient medical records because I love and live to learn about all aspects of being a medical professional. I believe dealing with bith inpatient and outpatient medical records will further my knowledge about medical records as well.

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ME1750: Week 5 Assignment 

How do you accomplish accurate transcription of medical  documents using correct formats and reference materials?

This assignment helps you apply your knowledge from this week’s module 

and readings.

In this assignment, you will put together all the knowledge that you have 

learned to be a skilled Medical Transcriptionist in the field. You will 

demonstrate the MT’s core competencies as you transcribe medical 

documents, using correct formats and reference materials.

Using Reference Tools

Choose the best answer.

1. The medical term which describes a rapid and random quivering of ventricles during which no blood is pumped is:      

× Ventricular fibrillation

☐ Ventricular tachycardia

☐ Ventriculocisternostomy

☐ Ventrillations

2. Which one of the following is the brand name for lidocaine, a topical anesthetic?      

☐ Coumadin

× Xylocaine

☐ Hemoccult

☐ Oxocaine

3. What is the correct spelling of the word that describes an enlargement of the liver and spleen?    

× Hepatosplenomegaly

☐ Splenomegaly

☐ Hepatospleen

☐ Hepatospleenomegoly

4. What is the correct spelling of the word that describes a procedure in which the structure of a heart  vessel is altered using a balloon inside the lumen?      

☐ angeoplasty

× angioplasty

☐ angeoplasti

☐ angioplasty

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5. What does COPD stand for?      

☐ Common Obstruction Post Dermis

× Chronic Obstructive Palpitation Disease

☐ Chronic Obstructive Pulmonary Disease 

☐ Commonly Obstructed Pelvic Dissociation

6. An English dictionary provides a collection of words in one or more specific ___________, often  alphabetically.      

× Meanings

☐ Words

☐ Languages

☐ Pages

7. The following drug reference book is written specifically for medical transcriptionists by a certified  medical transcriptionist and lists generic and brand name drugs, as well as how they are used  and prescribed.       

☐ The Sloane’s Medical Word Book

☐ The American Drug Index

× The Saunders Pharmaceutical Drug Book

☐ The Physician’s Desk Reference

8. In addition to drugs, the Physician’s Desk Reference lists all of the following, EXCEPT:      

☐ Products used in skin tests

× Surgical instruments

☐ Injectable materials used in diagnostic tests

☐ Products used in laboratory tests

9. If the MT, wanted to verify foreign words and phrases not generally used in English, signs and  symbols, and chemical elements, where in the English dictionary would you look for such  secondary references?      

× in the back of the dictionary

☐ in the foreword of the dictionary

☐ in the main body of the dictionary

☐ in the middle of the dictionary

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10. French terms are common in medicine. Which reference book could an MT use to verify the correct  spelling of medical terms with French roots?      

× The Sloane’s Medical Word Book

☐ The Physicians’ Desk Reference

☐ Vera Pyle’s Current Medical Terminology

☐ The Medical Transcription Guide Do’s and Don’ts

11. List the correct spelling of the bolded words in the following physical exam transcript.      

Chest: Reveals a resp­ire­ah­tore­ee rate of approximately sixty five without retractions.  Respirations appear somewhat shallow. There are bilateral coarse breath sounds  bilaterally without we­zez. The air movement is good.  

Car­dee­oh­vask­you­lar exam: Reveals a normal sinus rhythm; a normal ess one and  ess two. There are no murmurs. The pulses are sim­eh­trick and equal in upper and  lower extremities.

Abdomen: Soft and nontender without hep­at­oh­splen­oh­meg­ah­lee, without masses, and has normal bowel sounds.

GU: Reveals a normal female without discharge.

Extremities: Has full range of motion without air­eh­theme­ah. 

Bolded Script Terms

Correct Transcripted Terms

a.

resp­ire­ah­tore­ee

Respiratory

b.

sixty five

65

c.

we­zez

Wheeze

d.

car­dee­oh­vask­you­lar

Cardiovascular

e.

ess one and ess two

Type answer here

f.

sim­eh­tick

Type answer here

g.

nontender

Type answer here

h.

hep­at­oh­splen­oh­meg­ah­lee

Hepatosplenomegaly

i.

air­eh­theme­ah

Type answer here

Reflection  

Reflect on what you have learned this week to help you respond to the question below. You may  choose to respond in writing or by recording a video!

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12. Share your best tip or trick you learned from transcribing medical reports and using reference tools.   Explain your best tip or trick and what it helped you accomplish.         

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