Fluent Essays

Need help completing medical transcriptionist assignments. Letter 21 Letterhead April 14, 2012 Mr Eric Ojeda 85 Westwind Way Northfolk, VA 07225 Dear Mr Ojeda RE: Conservatorship, Elmer Edward Essing I am writing you in regard to my psychiatric evaluation of the above-named individual, conducted at Sweetwater Home Board and Care on November 5, 2012. I was requested by his wife to evaluate the patient psychiatrically because of the difficulty he has been experiencing recently in terms of confusion and agitated behavior. His wife asked me to evaluate him at Sweetwater as it is very difficult for her to transport the individual to my office because he is confused disoriented and at times hostile and belligerent. According to the records, the patient is 69 years of age, has a history of rheumatic heart disease with mitral stenosis that is severe, C. H. F., afib, with history of multiple cerebral emboli that probably has caused senile dementia. He did not appear to recognize the purpose of the interview, nor did he appreciate the opportunity to present his view to the interviewer. He was able to state his name but was generally thoroughly hostile and openly oppositional and sarcastic during the interview. He refused to give me many details of his past history relating that I don’t need your help. The patient himself did not speak spontaneously; he tended to repeat over and over again that he did not need help, that all he needed was his wife to take him out of Sweetwater. He did not appear to be able to give me the current date, time, year or month, nor was he able to give his location in terms of city or state. He refused to answer most of my questions, but it was apparent that the patient at times tended to confabulate and avoided answering questions that he would have difficulty with by being openly hostile. He had a very constricted effect that was at times labile, openly so, in anger and disgust. His mood was depressed, with some history of sleep disturbance, but he denied any suicidal ideation or any selfdestructive behavior periods. (continued) Date RE: Conservatorship, Elmer Edward Essing Page 2 Hypothesis: The patient had general difficulty completing thought trends. He denied any hallucinations or delusions, but his guardedness would indicate possible paranoid ideation with possible unsystemized persecutory delusional system. He felt there was some type of conspiracy against him to place him at Sweetwater Home Board and Care. He was unable to recognize and appreciate his medical and mental circumstances appropriately and respond to them in an appropriate manner. Judgement was impaired since the patient could not make medical or financial decisions in his best interest. I do not feel that he knows the extent of his medical illness or his financial situation. The patient was disoriented to time, person and place. IMPRESSION: Organic brain syndrome, probably secondary to multiple cerebral embolus from history of rheumatic H.D. and atrial fibrillation. At this point in time, I feel that the patient is gravely disabled, that he cannot provide food, shelter, or clothing for himself nor make decisions in regard3 to his medical or financial affairs in his best interest. I recommend that he be continued in a structured living situation with supervision of medication and recommend conservatorship of person and property. If further information is needed, please feel free to contact me at any time. Sincerely Philip B. Michaelson, MD jk Letter 11 Letterhead Date: July 17 2014 Winthrop G. Macdonald, MD 5700 Fifth Ave Philadelphia Pa 17532 Dear Mac RE: Laverne Lampe Thank you for referring Mrs Lampe to my office for gynecological evaluation. She was first seen on November 10, 2103, but this report was intentionally delayed until the results from the endometrial biopsy where obtained. At the time of the initial visit Mrs Lampe stated that she had had no menses for 6 to 7 months. However, beginning about 3 to 4 weeks ago she developed a clear discharge which was blood-tinged during the week of her visit. She denied any pain associated with this bleeding. As you are familiar with her past history and review of systems these will not be reiterated at this time. Gynecological examination revealed the following: Breasts: Symmetrical. No masses, tenderness, or induration. No axillary adenopathy. Abdomen: Flat. Liver, spleen, and kidneys not felt. No masses, tenderness, or hernias. Pelvic: External genitalia normal with normal female escutcheon. The introitis is parous. Perinea is intact. Bartholin and skene urethral glands are normal. There is no significant cystocel or rectocel. The vaginal mucosa is healthy in appearance. Direct visualization of the cervix revealed a small cervical polyp at six o’clock, which was removed. Bimanual palpation revealed the uterus to be retro-displaced, symmetrical in contour and slightly enlarged. The adnexal regions and the culdesac felt normal. As noted above, the cervical polyp was removed. July 17 2014 RE: Laverne Lampe Page 2 An endometrial biopsy was done, and the uterus measured 9 CM in depth, which represents a slight enlargement. A large amount of hyperplastic/appearing tissue was obtained on the biopsy. As you know from your copy of the biopsy report, she does have a grade three cystic endometrial hyperplasia with focal adenomatous hyperplasia. This information was conveyed to Mrs Lampe, and the treatment indicated is a curettage. While I doubt if she has a malignancy, removal of all this hyperplastic tissue is indicated to make sure she does not have an in situcarcinoma present. She is a very apprehensive woman, and at this time, it is unknown whether she will proceed with the recommended surgery. If she does return for the curettage, I will see that you receive a copy of the surgical dictation and the pathology report. Thank you again for your kindness in referring Mrs Lampe and for allowing me to assist with her care. Warmest personal regards. Very truly yours Martin P. Douglas, MD Copy: Frank Horowitz MD Blues 101435.555 Blues 103812.93 Blues 188144.42 Blues 254737.05 READING ASSIGNMENT Your project must be submitted as a Word document (.docx, .doc)*. Your project will be individually graded by your instructor and therefore will take up to a few weeks to grade. Be sure that each of your files contains the following information: · Your name · Your student ID number · The exam number · Your email address To submit your graded project, follow these steps: · Log in to your student portal. · Click on Take Exam next to the lesson you’re working on. · Find the exam number for your project at the top of the Project Upload page. · Follow the instructions provided to complete your exam. Be sure to keep a backup copy of any files you submit to the school! Instructions To access the recorded dictations and transcribed reports used to complete your project, click here. 1. Transcription Assignment 1: Letter 2 Access the recorded dictation as provided and prepare the letter. Be sure to transcribe the letter as dictated. 2. Transcription Assignment 2: Letter 7 Access the recorded dictation as provided and prepare the letter. Be sure to transcribe the letter as dictated. 3. Editing Assignment 1: Letter 11 Access the transcribed letter and audio file, and edit the letter for errors in spelling, punctuation, grammar, and letter format. 4. Editing Assignment 2: Letter 21 Access the transcribed letter and audio file, and edit the letter for errors in spelling, punctuation, grammar, and letter format. How to Complete the Assignments 1. Type or proofread each letter in the order given. 2. Review your work carefully. For the transcription assignments, it’s a good idea to replay your file and listen to it as you read each report. You’ll be able to catch any errors and reinforce your terminology at the same time. Don’t rely on a computer spell checker. For the proofreading and editing assignments, reread the document to find additional errors you may have missed. It may also help to read the document aloud to catch any mistakes you might have missed. 3. Be sure to include your name, student number, Medical Transcription 1 Graded Project, and examination number (03983600). In addition, include the title of the assignment in the top right corner. For example, the titles of the assignments you’ll submit are as follows: · Transcription Assignment 1: Letter 2 · Transcription Assignment 2: Letter 7 · Editing Assignment 1: Letter 11 · Editing Assignment 2: Letter 21 4. Single-space the bodies of the reports to be submitted. 5. Follow the exact format provided in the dictated recording. Use your initials and the current year for submitted reports. 6. If you can’t understand a word or phrase in the dictation, check your medical dictionary and the terminology section of the corresponding chapter in your textbook. If a word has already been given in the terminology section of a previous chapter, it will be used again without being listed—once you use a word, you’re expected to remember it. You may have to check earlier chapters’ lists to find the word. Also check the lists of medical terms and the lists of drugs, instruments, tests, and other terms in the Appendix. 7. If you’re still unable to transcribe the word, make an educated guess. If you can’t transcribe a word, it’s better to leave a blank space on your dictation and properly flag the missing entry than to guess and use the wrong word. Please refer to your textbook for information on proper flagging. Submitting Your Project You must submit these four-letter assignments in ONE word-processing document and not as individual files in a folder. If you’ve completed the assignments as individual documents, you’ll need to copy and paste all assignments into ONE word-processing document. Acceptable formats for submitting your work include Microsoft Word documents (.doc and .docx) or Rich Text Format (.rtf). No other format is to be used for submitting this project. · Transcription Assignment 1: Letter 2 · Transcription Assignment 2: Letter 7 · Editing Assignment 1: Letter 11 · Editing Assignment 2: Letter 21 Each assignment is individually graded by your instructor and therefore takes up to a few weeks to grade. Grading Criteria Transcription Ability to transcribe letters and medical reports from audio files Part 1: Transcribe Completely All transcribed reports/letters must be accurate and complete. Errors: · Missing words or additional words · Missing sentence · Missing paragraphs · Missing letterhead Maximum possible points = 4 If the error is demonstrated 1-5 times, 2-point deduction Error demonstrated more than 5 times = 4 points deductions Part 1: Written Communication Free of ID Errors: 1. Complete date, in a traditional format, on all letters, reports, and entries into the medical record and official documents. 2. Include reference initials Maximum possible points: 4 If the error is demonstrated: 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Error demonstrated more than 16 times: 4-point deduction Part 1: Accuracy Drug Name/Lab Values 1. Medications can be transcribed in the generic form or the brand-name form of the medication. 2. The proper format for transcribing numerals and decimals. 3. Use of the abbreviation "ml" or "mL" in place of the abbreviation "cc." 4. Format for transcribing numerals with a label. Maximum possible points = 4 If the error is demonstrated: 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times = 3-point deduction Error demonstrated more than 16 times = 4-point deduction Part 1: Accurate Abbreviations 1. Specific parts of the medical reports where abbreviations are not allowed. 2. Use of the abbreviation used for suture materials Maximum possible points = 4 If the error is demonstrated: 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Error demonstrated more than 16 times: 4 points deduction Part 1: Correct Use of Numerals 1. Transcribe numbers in medical reports as numerals. 2. Use of roman numerals Maximum possible points = 4 If the error is demonstrated: 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Error demonstrated more than 16 times = 4-point deduction Part 1: Flag Not recommended in your graded project. Use correct procedure. Maximum possible points: 4 If the error is demonstrated: 1-5 times = 1-point deduction 6-10 times = 2-point deduction 11-15 times = 3-point deduction Error demonstrated more than 16 times = 4-point deduction Part 1: Misspelled Medical Terms/Words 1. Care in proofreading the report for misspelled words. 2. Word "follow up" is common in medical dictation. 3. Correct use of eponyms Maximum possible points: = 4 If the error is demonstrated: 1-5 times = 1-point deduction 6-10 times = 2-point deduction 11-15 times = 3-point deduction Error demonstrated more than 16 times = 4-point deduction Part 1: Accuracy Verb Tenses Take care in selecting the verb tense used in letters and medical reports Maximum possible points = 4 If the error is demonstrated 1-5 times = 1-point deduction 6-10 times = 2-point deduction 11-15 times = 3-point deduction Error demonstrated more than 16 times = 4-point deduction Part 1: Correct Use of Punctuation 1. Uses for the comma 2. Uses for the hyphen. Maximum possible points = 4 If the error is demonstrated 1-5 times = 1-point deduction 6-10 times = 2-point deduction 11-15 times = 3-point deduction Error demonstrated more than 16 times = 4-point deduction Part 2: Format 1. Three formats for transcribing letters, the parts of the letter, and the spacing of the parts of the letter on the page. 2. Reference line in the location Maximum possible points = 2 If the error is demonstrated 1-5 times: 1-point deduction Error demonstrated more than 5 times = 2-point deduction Part 2: Format Correct information in the second page heading. Max possible points = 2 If the error is demonstrated 1-5 times = 1-point deduction Error demonstrated more than 5 times = 2-point deduction Part 2: Format Follow the dictated information as presented on the audio file Maximum possible points = 2 If the error is demonstrated 1-5 times = 1-point deduction Error demonstrated more than 5 times = 2-point deduction Part 2: Format Paragraphing in medical reports can be difficult. Maximum possible points = 2 If the error is demonstrated 1-5 times = 1-point deduction Error demonstrated more than 5 times = 2-point deduction Part 2: Format The signature block includes the typed signature line of the author of the letter, note or report, the initials of the dictator and transcriptionist, and the date of dictation and the date of transcription. Maximum possible points = 2 If the error is demonstrated 1-5 times, 1-point deduction Error demonstrated more than 5 times = 2-point deduction Part 3: Miscellaneous Additional errors recorded by grader. Maximum possible points = 10 Total points = 60 Editing Please read the instructions in the study guide and copy and paste the entire report for the editing assignment. Part 1: Written Communication Clarity and complete thought: Listen to the audio file and read the provided report before attempting to begin the editing process. Maximum possible points = 4 If the student has correctly completed the assignment, no point deduction. Part 1: Accuracy Drug Name/Lab Values 1. Medications can be transcribed in the generic form or the brand-name form of the medication 2. The proper format for transcribing numerals and decimals 3. Use of the abbreviation "ml" or "mL" in place of the abbreviation "cc." Maximum possible points = 4 If the error is demonstrated 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Error demonstrated more than 16 times = 4-point deduction Part 1: Accuracy Abbreviations 1. Specific parts of the medical reports where abbreviations are not allowed. 2. Use of the abbreviation used for suture materials. 3. Use numerals when numbers are used directly with symbols, words, or abbreviations. Maximum possible points: 4 If the error is demonstrated: 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Error demonstrated more than 16 times = 4-point deduction Part 1: Accuracy Numerals 1. Transcribe numbers in medical reports as numerals. 2. Use of Roman numerals. 3. Format for transcribing numerals with a label Maximum possible points = 4 If the error is demonstrated 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Part 1: Accuracy Verb Tenses Take care in selecting the verb tense used in letters and medical reports Maximum possible points: 4 If the error is demonstrated 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Error demonstrated more than 16 times = 4-point deduction Part 1: Misspelled Medical Terms/Words 1. Care in proofreading the report for misspelled words 2. Word "follow up" is common in medical dictation Maximum possible points = 4 If the error is demonstrated 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Error demonstrated more than 16 times = 4-point deduction Part 1: Correct Use of Punctuation 1. Uses for the comma 2. Uses for the hyphen Maximum possible points = 4 If the error is demonstrated 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Part 1: Correct Signature Block Typed signature line of the author of the letter, note, or report; the initials of the dictator and transcriptionist, and the date of dictation and the date of transcription Maximum possible points = 4 If the error is demonstrated, 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Error demonstrated more than 16 times: 4-point deduction Part 1: Correct Use of Capital Letters Use of capital letters in medical transcription Maximum possible points = 4 If the error is demonstrated 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Error demonstrated more than 16 times = 4-point deduction Part 2: Format Format is not graded in the editing portion of the graded project because the format is presented to the student in the report provided. Part 3: Miscellaneous Additional errors noted by the grader Maximum possible points = 4 Total points = 40