Hillcrest Medical Center

Patricia A. Ireland, CMT, AHDI-F, has been active in the field of medical transcription since 1968, both as a multispecialty practitioner and as an instructor. A certified medical transcriptionist since 1981, Ms. Ireland lives in San Antonio, Texas, where she works as a freelance medical/technical author and editor. She has been a medical transcription instructor since the 1970s, has taught online medical transcription programs since 2000, and has co-authored four medical transcription textbooks for Cengage Learning. Ms. Ireland encourages questions and comments about this text and can be reached at pat.ireland68@yahoo.com. Ms. Ireland is an active member of the Association for Healthcare Documentation Integrity (AHDI), as well as the Capital Chapter of AHDI in Austin, Texas. Carrie Stein, CMT, had over 32 years of experience as an acute-care multispecialty medical transcriptionist when she passed away in late 2015. Her long career included positions with the University of Texas Medical Branch in Galveston, Texas, and the Methodist Healthcare System in San Antonio, Texas. She began teaching online medical transcription courses in 2003, serving as an instructor for Gatlin Education and ed2go. In addition to this title, Carrie was the co-author of THE DICTATED WORD.

Preface.
Prerequisites.
New to this Edition with Featured Items.
Course Description.
Objectives.
Student Text-Workbook.
Instructor's Manual.
About the Authors.
Supplements at a Glance.
How to Use StudyWARE™.
SECTION 1INTRODUCTION.
Welcome to Hillcrest Medical Center.
Confidentiality Policy.
Legal Issues.
Objectives.
Length of Course.
Certification.
Transcribing Medical Reports.
Evaluations.
Expand Your Knowledge: Word Games and Exercises.
Listing of Appendix.
Association for Healthcare Documentation Integrity.
Medical Transcriptionist Job Descriptions.
AHDI Code of Ethics.
Certification Possibilities—RMT and CMT.
Health Insurance Portability & Accountability Act: MT checklist.
Understanding Medical Records.
History and Physical Examination (H&P).
Diagnostic Imaging or Radiology Report
Operative Report (OP).
Pathology Report (Path).
Consultation (Consult).
Discharge Summary.
Death Summary.
Autopsy Report.
Outpatient Model Reports.
SECTION 2MODEL REPORT FORMS.
SECTION 3REFERENCES.
Transcription Rules for Hillcrest Medical Center and Quali-Care Clinic.
Style Variations.
Capitalization.
Numbers.
Punctuation.
Abbreviations and Symbols.
List of Metric Measurements.
The Grammar of Microbiology.
Vital Signs.
CMTips™.
Difficult Singular and Plural Words and Phrases.
Temperature versus Fever.
A Tongue Twister.
Dermatology Terms.
Pulmonary Terms.
Race/Age.
Zero Safety.
The Digits.
Time.
Abduction versus Adduction.
Class and Stage.
Connective Tissues.
Subjective versus Objective.
Surgical Terms.
Obstetric Terms.
Cardiology Terms.
The ABO Blood Group.
Jr, Sr, II, and III.
Report Formatting Guidelines.
The Future of Medical Transcription.
Skill-Building Report Log.
Doctors' and Other Professional Names Used.
Understanding Medical Terminology.
Principles.
Prefixes/Pronunciation.
Combining Forms.
Suffixes.
SECTION 4CASE STUDIES.
Case 1 The Reproductive System.
Glossary.
Case 2 The Gastrointestinal System.
Glossary.
Case 3 The Cardiopulmonary System.
Glossary.
Case 4 The Integumentary System.
Glossary.
Case 5 The Psychology Neurology System.
Glossary.
Case 6 The Nervous System.
Glossary.
Case 7 The Orthopedics/Endocrinology System.
Glossary.
Case 8 The Vascular/Renal System.
Glossary.
Case 9 The Musculoskeletal System.
Glossary.
Case 10 The Respiratory System.
Glossary.
SECTION 5QUALI-CARE CLINIC.
Welcome to Quali-Care Clinic.
Quali-Care Clinic Outpatient Report Log.
Outpatient Reports.
Report 1a&b Consult & Echocardiogram (Cardiology).
Report 2 Operative Procedure (Genitourinary).
Report 3 Operative Report (Orthopedics).
Report 4 Surgical Pathology Report (Breast).
Report 5 Emergency Dept Treatment Record (Pediatrics).
Report 6 Interventional Radiology (Vascular).
Report 7 Spine Clinic HPIP Note (Orthopedics).
Report 8 Radiology Report (Orthopedics).
Report 9 Clinic SOAP Note (Vascular).
Report 10 Surgical Procedure (Orthopedics).
Report 11 Operative Report (Plastic Surgery).
Report 12 Colonoscopy Procedure (Gastroenterology).
Report 13 Clinic HPIP Note (Internal Medicine).
Report 14 Operative Report (Neurosurgery).
Report 15 Operative Report (Urology).
Report 16 Radiology Report (Orthopedic/Neurology).
Report 17 Clinic Followup Note (Pediatric Neurology).
Report 18 Operative Report (Obstetrics).
Report 19 Operative Report (Orthopedics).
Report 20 Clinic Followup Note (Vascular).
Report 21 Operative Report (Dentistry).
Report 22 Operative Report (Orthopedics).
Report 23 Consult (Orthopedics).
Report 24 Psychological Evaluation (Psychology).
Report 25a&b Letter & Consult (Cardiology).
SECTION 6 EXPAND YOUR KNOWLEDGE.
Crossword Puzzles 1 through 17.
Proofreading Exercises 1 through 12.
Common Dictation Errors.
Appendix.
Proofreader's Marks.
Challenging Medical Words, Phrases, Prefixes.
Sample Patient History Form.
The Lund Browder Chart.
Laboratory Test Information.
Sample Forms for Ordering Laboratory Tests, Scheduling Radiology Tests.
Physical Therapy Consults, Sleep Studies.
Building a Reference Library.
Web Sites for Transcriptionist' Professional Association.
A Healthcare Controlled Vocabulary" by Dr. Neil Davis.
Official "Do Not Use" List from The Joint Commission.
Bibliography.
Index."