Wednesday 23 October 2013

Medical Transcription - A Rewarding Career

Introduction
Medical transcription, widely known as MT, is one of the fastest growing fields in many western and Asian countries, including India.  It is a process in which one accurately transcribes and edits the content dictated by physicians and other health professionals concerning a patient's health care.  The majority of these physicians and health professionals are from USA; however, there are dictators from UK, Australia, and Canada also.

In USA, when a patient visits a doctor, the doctor discusses his medical problems, including his present history, past medical history, family history, social history, habits, etc.  Then, the doctor performs physical examination on the patient.  He may also request some diagnostic and laboratory tests to be performed, if necessary, so as to make proper diagnosis and treatment plan.  After consulting the patient, the doctor uses a voice recorder to record the necessary information given by the patient as well as the findings obtained from physical examination.  The voice file then goes to a medical transcriptionist who listens to the whole dictation and transcribes the report using proper format and guidelines given by the doctor.  The transcriptionist uses headphone, foot pedal, etc., to type out the report.  After completion, the transcriptionist sends the typed report to the doctor, which is considered a legal document.

There are mainly five types of report that are dictated by a dictator, e.g., History and Physical Examination, SOAP Note, Consultation, Operative Report, and Discharge Summary.

In a nutshell, a medical report looks like the following:
PATIENT NAME:  xxxx xxxx
MR#:  xxxxxxx
DOB: 00/00/0000
DATE OF VISIT:    00/00/0000

HISTORY OF PRESENT ILLNESS:  The patient is an 82-year-old male who has a known history of hypertension and CAD.  He reports that everything is "okay."  He describes occasional headaches and little bit of cough with rare white sputum.  He denies sore throat or chest pain.  He reports occasional nausea but denies abdominal pain, vomiting, or diarrhea.  He denies dysuria.  He also reports anxiety for which he takes Xanax p.r.n.  He denies any rashes.  He underwent previous PTCA and stenting procedures last year.  Since that time, he has been relatively stable with medical management.  He reports smoking occasionally.  Typically, he smokes when he has a beer.

PAST MEDICAL HISTORY:
1.  Hypertension and CAD.
2.  Chronic cough.
3.  Dyslipidemia.

ALLERGIES:  None.

MEDICATIONS:  Aspirin 81 mg daily, Plavix 75 mg daily, metoprolol 50 mg b.i.d. and Lipitor 10 mg q.h.s.

SOCIAL HISTORY:  He occasionally smokes.  He does not abuse alcohol.

FAMILY MEDICAL HISTORY:  His mother died of colon cancer.  His father died of gastric carcinoma.   One brother has hypertension.

PHYSICAL EXAMINATION:  Vital signs:  Blood pressure 120/80, pulse 80, respirations 17, and temperature 98.2 degrees Fahrenheit.  He weighs 185 pounds.  He is 5 feet 9 inches.  In general, this is an elderly-appearing, pleasant male, currently in no cute distress.  Throat is benign.  Neck is supple.  Carotids have 2+ upstrokes bilaterally without bruits.  Chest has a normal AP diameter.  Lungs are clear to auscultation and percussion.  No murmurs, clicks or gallops.  Abdomen is soft, nontender, and nondistended.  Good bowel sounds present.  Face is symmetrical.  He has a normal gait.

DIAGNOSES:
1.  Coronary artery disease.
2.  Hypertension.
3.  Chronic cough.
4.  Dyslipidemia.

PLAN:  The patient is advised to continue his medications as prescribed.  We will repeat labs today.  She will be followed up in approximately four weeks’ time.  At that time, any changes in treatment plan or further treatment will be determined.

Voice Recognition Technology
In this day and age, with the help of advanced technology, many providers use a method of transcription called “speech or voice recognition.”  Though the voice recognition software types out the report without human intervention, it still cannot produce a 100% accurate report and an experienced transcriptionist is needed to check the report and make it an error-free document.  Voice recognition technology is still in a nascent stage.

Career
A career in medical transcription can be rewarding especially for those who have a capacity for hard work.  The demand for qualified medical transcriptionists is augmenting day by day.

Course Duration
The overall duration varies anywhere from 6-12 months, depending on the training center.  Short-term online courses are also available.

Skills and Abilities
You can take medical transcription as a career if you have the following basic skills:
Ø  Excellent command over English, including the knowledge of and proper application of grammar.
Ø  The ability to follow verbal and written instructions.
Ø  Basic computer application skills.
Ø  Above average typing speed.
Ø  Ability to work for long hours.
Ø  High level of concentration.

Course Module
A medical transcription course mainly comprises the following:
Ø  Human anatomy, pathophysiology, and disease processes.
Ø  Medical terminology.
Ø  Surgical procedures.
Ø  Pharmacology.
Ø  English grammar.
Ø  Typing practice.

Advantages

To become a medical transcriptionist, you will not need an advanced college degree.  You just need to join a good training center from where you will become familiar with all the aspects related to this promising career.  The main advantage of becoming a medical transcriptionist is that you can work from home also.  To start with, all you would need is a computer, internet connection, a headphone, and a foot pedal.  As it is primarily an incentive-based job, you can earn as much as you want provided that you keep quality as top priority.  There are many transcriptionists available nowadays, yet excellent ones are relatively hard to find.

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Saturday 19 October 2013

Formation of Medical Words

Medical words are very easy to remember.  Once you learn how to form a medical word, it will become easier for you to know the meaning of each medical word that you come across.  Medical words are formed from word roots, prefixes, suffixes, and combining forms.

Let’s take the word hyperlipoproteinemia.  It has prefix, word root, suffix, and combining form, as shown below.

hyper- is the prefix, which means excessive
lip is the root, which means fat
 o is the combining form (lip/o)
protein is the root
-emia is the suffix, which means blood condition.

So, hyperlipoproteinemia means excessive fat and protein in the blood.

Prefixes:  Prefixes are added to the beginning of a word to make a new word.  E.g., hyper-, peri-, brady-, etc.

Suffix:  Suffixes are added to the end of a word to complete a new word.  E.g., -logy, algia, -oma, etc.

Root:  Root is the central part of a word.  E.g., aden, cardi, etc.

Combining Form:  Formation of a new term with a vowel attached to the word root (word root + vowel) is called a combining form.  The most common vowel used in the formation of the combining form is the letter “o” added to the word root.  E.g., aden/o, cardi/o, etc.

You must have come across the suffix “-logy;”
-logy (suffix) means study of or science of.
·         Biology:  Bi/o means life, so biology means study of life.
·         Anthropology:  Study of humankind (anthrop/o means humankind).
·         Cardiology:  Study of heart (cardi/o means heart).
·         Zoology:  Study of animal life (zoo means animal or animal life).
·         Psychology:  Study of mind (psych/o means mind).
·         Dermatology:  Study of skin (dermat/o means skin).
·         Ecology:  Study of environment (ec/o means environment).
·         Etiology:  Study of cause of disease (eti/o means cause of disease).
·         Gastroenterology:  Study of gastrointestinal tract (gastr/o means stomach, enter/o means intestines).
·         Gynecology:  Study of female genital organs (gynec/o means female).
·         Andrology:  Study of male genital organs (andr/o means male).

-logist (suffix) means specialist.
·         Anthropologist:  Specialist in the study of humankind.
·         Biologist:  Specialist in the study of life.
·         Cardiologist:  Specialist in the study of heart or heart diseases.
·         Gastrologist:  Specialist in the study of stomach.

-algia, -dynia (suffix) means pain.
·         Otalgia/otodynia:  Pain in the ear; earache (ot or ot/o means ear).
·         Odontalgia:  Pain in the tooth or teeth; toothache (odont or odont/o means tooth or teeth).
·         Cephalalgia:  Pain in the head; headache (Cephal/o means head).
·         Mastodynia:  Pain in the breast (mast/o means breast).
·         Gastralgia:  Pain in the stomach; stomach ache (gastr/o means stomach).
·         Arthralgia:  Pain in a joint (arthr or arthr/o means joint).

-scopy (suffix) means to examine; physicians usually use a scope (instrument).
·         Rhinoscopy:  Visual examination of the nose (rhin/o means nose).
·         Gastroscopy:  Visual examination of the stomach, through an endoscope.
·         Arthroscopy:  Visual examination of the interior of a joint, through an endoscope.
·         Otoscopy:  Visual examination of the ear, especially eardrum.
·         Ophthalmoscopy:  Visual examination of the eye, especially the fundus of the eye, through an ophthalmoscope.

-gram, -graphy (suffix) means record, usually done through an instrument; often radiopaque contrast material is injected in the body.
·         Angiogram/angiography:  Record of blood or lymph vessels (angi/o means blood or lymph vessels).
·         Cardiogram/cardiography:  Record of heart or heart muscles (cardi/o means heart).
·         Cholangiogram/cholangiography:  Record of bile duct (chole- means bile and angi/0 means blood or lymph vessels)
·         Encephalogram/encephalography:  Record of the brain (encephal/o means brain).
·         Mammogram/mammogram:  Record of the breasts (mamm/o means breasts)

-itis (suffix) means inflammation.
·         Arthritis:  Inflammation of a joint.
·         Carditis:  Inflammation of the heart.
·         Gastritis:  Inflammation of the stomach.
·         Hepatitis:  Inflammation of the liver.
·         Pancreatitis:  Inflammation of the pancreas.
·         Rhinitis:  Inflammation of the nose.

-osis (suffix) means abnormal condition.
·         Cirrhosis:  Abnormal condition of the liver.
·         Psychosis:  Abnormal condition of the mind.
·         Xerosis:  Abnormal condition or dryness of the skin, conjunctiva, or mucous membranes.

-al, -ic, -ar (suffix) means pertaining to or relating to.
·         Abdominal:  Pertaining to abdomen.
·         Cardiac:  Pertaining to heart.
·         Hepatic:  Pertaining to liver.
·         Cardiac:  Pertaining to heart.
·         Pericardial:  Pertaining to surrounding of the heart.

Peri- (prefix) means around, surrounding, or near.
·         Periarterial:  Pertaining to surrounding an artery.
·         Perihepatic:  Pertaining to surrounding the liver.
·         Periadenitis:  Inflammation of the tissues surrounding a gland.
·         Perithyroiditis:  Inflammation of the capsule or tissues surrounding the thyroid gland.
·         Periureteritis:  Inflammation of the tissues surrounding a ureter.

Pre- (prefix) means before, in front of, or anterior.
·         Precardiac:  Pertaining to anterior part of the heart.
·         Prenatal:  Pertaining to before birth.
·         Preoral:  In front of the mouth.
·         Prepatellar: Pertaining to anterior to the patella.
·         Preauricular: Pertaining to anterior to the auricle of the ear.

Brady- (prefix) means slow.
·         Bradycardia:  Pertaining to slow heartbeat.
·         Bradypepsia:  Pertaining to slowness of digestion.
·         Bradypnea:  Abnormal slowness of respiration.
·         Bradyuria:  Pertaining to slow micturition (urination).

Tachy- (prefix) means rapid or quick.
·         Tachycardia:  Pertaining to rapid heartbeat.
·         Tachypnea:  Rapid breathing.

Dys- (prefix) means difficult or painful.
·         Dysphagia:  Difficulty in swallowing.
·         Dysuria:  Difficulty or pain in urination.
·         Dysmenorrhea:  Difficult and painful menstruation.
·         Dyspnea:  Difficulty in breathing.
·         Dyslexia:  Difficulty in or impaired reading ability.

Given below is a list of most common prefixes, suffixes, and roots.  Once you learn this, it will become easier for you to form and remember medical words.

PREFIXES
MEANING
a-, an-
without, lacking
ante-
before, in front
bi-
two
brady-
slow
contra-
against
cry-
cold
dys-
difficult, painful
ex-, exo-
outer or outside
end-,endo-
within or inner
epi-
above or upon
eu-
normal or good
hemi-
half
hyper-
excessive
hyp-, hypo-
deficient or below
infra-
below or beneath
inter-
between
intra-
within
mal-
bad
micro-
small
multi-
many
neo-
new
nulli-
none
pan
total, all
para-
around, beside or along
peri-
around
poly-
many
pre-
before, in front of
retro-
back or behind
semi-
half
sub-
under
super-
over, above
supra-
above
tachy-
fast or rapid
trans-
through
tetra-
four
ultra-
beyond or excess
uni-
one


ROOT WORD with combing form
MEANING
Aden/o
gland
Blephar/o
eyelid
cardi/o
heart
derm/o or dermat/o
skin
gastr/o
stomach
lingu/o
tongue
phob/o
fear
thorac/o
chest
abdomin/o
abdomen
andr/o
male
Algesi/o
pain
Arteri/o
artery
Arthr/o
joint
Articul/o
joint
Atri/o
atrium
Aur/o
ear
Aut/o
self
Bi/o
life
blephar/o
eyelid
Brachi/o
arm
Bronch/o
bronchus
Bucc/o
cheek
Burs/o
bursa (cavity)
Carcin/o
cancer
Cardi/o
heart
Celi/o
abdomen
Cephal/o
head
cervic/o
cervix
cheil/o
lip
chir/o
hand
cholangi/o
bile duct
choledoch/o
common bile duct
chondr/o
cartilage
col/o
colon
conjunctiv/o
conjunctiva
corne/o
cornea
coron/o
heart
cost/o
rib
crani/o
cranium (skull)
cyst/o
bladder; sac
dent/o
tooth
dermat/o
skin
diaphor/o
sweat
dipl/o
two or double
dips/o
thirst
encephal/o
brain
enter/o
intestines
esophag/o
esophagus
esthesi/o
sensation, sensitivity, feeling
eti/o
cause (of disease)
gastr/o
stomach
gingiv/o
gum
glyc/o
sugar
gravid/o
pregnancy
gynec/o
woman
gyn/o
woman
hem/o
blood
hemat/o
blood
Hepat/o
liver
Herni/o
hernia
Leuk/o
white
mast/o
breast
men/o
menstruation
olig/o
scanty or few
ocul/o
eye
ophthalm/o
eye
oste/o
bone
orth/o
straight
ot/o
ear
path/o
disease
phalang/o
pharynx
phas/o
speech
phleb/o
vein
phot/o
light
phren/o
mind
pneumon/o
lung or air
polyp/o
polyp; small growth
pseudo/o
fake; false
psych/o
mind
ren/o
kidney
retin/o
retina
rhin/o
nose
somat/o
body
somn/o
sleep
ur/o
urine or urinary tract


SUFFIXES
MEANING
-agra
excessive pain
-algia, -dynia
pain
-cele
hernia or protrusion
-centesis
surgical puncture to remove fluid
-desis
surgical fixation; fusion
-ectasis
stretching out; dilatation; expansion
-ectomy
cut out, excision
-ectopia
displacement
-emesis
vomiting
-emia
blood condition
-gram, -graphy
record
-ism
state of
-ites, -itis
inflammation
-lepsy
seizure
-lysis
loosening; dissolution; separating
-malacia
softening
-mania
madness; insane desire
-megaly
enlargement
-meter
instrument used to measure
-metry
measurement
-morph
form or shape
-odia
smell
-odynia
pain
-oid
resembling
-logist
specialist
-logy
study of
-oma
tumor
-opia
vision
-opsy
to view
-rrhaphy
suturing or repairing
-rrhea
flow or excessive discharge
-osis
abnormal condition
-tomy
cut into or incision
-paresis
paralysis
-pathy
disease
-penia
deficiency, lack of
-pepsia
digestion
-phobia
fear
-phonia
sound or voice
-phoria
feeling
-pnea
breathing
-ptosis
dropping, sagging or prolapse
-rrhaphy
suture
-oma
tumor
-scope
instrument used for visual examination
-scopy, -scopic
to examine
-stomy
surgical opening
-tome
instrument used to cut
-tomy
cutting; incision