The Dictated Word

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.

SECTION 1: MEDICAL REPORTS
M- 1 Bone Marrow Transplant Followup Note
M- 2 Physical Medicine and Rehabilitation Consultation
M- 3 Orthopedic Clinic
M- 4 Emergency Department Treatment Record
M- 5 Vascular Surgery Followup Note
M- 6 Orthopedic Services Preoperative History and Physical
M- 7 Colorectal Surgery Consultation
M- 8 Neurosurgical Consultation
M- 9 Radiation Oncology Consultation
M-10 Bone Marrow Transplant Followup Note
M-11 Orthopedic Clinic Consultation
M-12 Vascular Surgery Followup Note
M-13 Emergency Department Treatment Record
M-14 Pediatrics Consultation
M-15 Radiation Oncology Followup Note
M-16 Vascular Surgery Followup Note
M-17 Vascular/Neurovascular Surgery Followup Note
M-18 Hematology/Oncology Bone Marrow Transplant Note
M-19 Internal Medicine Note
M-20 Emergency Department Treatment Record
M-21 Bone Marrow Clinic History and Physical Examination
M-23 Internal Medicine Followup Note
M-24 Hematology/Oncology Clinic Outpatient Progress Note
M-25 Physical Medicine and Rehabilitation Consultation
M-26 Emergency Room Treatment Record
M-27 Orthopedic Clinic Consultation
M-28 Bone Marrow Transplant Clinic Followup Note
M-29 Internal Medicine Followup Note
M-30 Physical Medicine and Rehabilitation Followup Note
M-31 Colorectal Surgery Consultation
M-32 Vascular Surgery Consultation
M-34 Orthopedic Followup Note
M-36 Orthopedic Followup Note
M-37 Ophthalmology (Emergency Department Record)
M-38 Hematology-Oncology Followup Note
M-39 Vascular Surgery Followup Note
M-40 Orthopedic Surgery History and Physical Examination
M-41 Colorectal Surgery Consultation
M-42 Emergency Room Treatment Record
M-43 Radiation Oncology Followup Note
M-44 Emergency Department Treatment Record
M-45 Bone Marrow Followup Note
M-46 Emergency Room Treatment Record
M-47 Orthopedic Followup Note
M-48 Vascular Consultation
M-50 Emergency Department Treatment Record
M-51 Orthopedic Clinic Consultation
M-52 Emergency Department Treatment Record
M-54 Oromaxillofacial Surgery Consultation
M-55 Discharge Summary
M-56 Preop History and Physical Examination
M-57 Emergency Department Treatment Record
M-59 Internal Medicine Clinic Followup Note
M-60 Plastic Surgery Clinic Followup Note
M-61 Nephrology Clinic Followup Note
M-62 Vascular Clinic Followup Note
M-63 Neurology/Orthopedics Discharge Summary
M-64 Radiation Oncology Clinic History and Physical Examination
M-65 Radiation Oncology Followup Note
M-66 Emergency Department Treatment Record
M-67 Vascular Surgery Consult
M-68 General Surgery Consult
M-69 Emergency Department Treatment Record
M-70 Orthopedic Discharge Summary
M-71 Orthopaedic Clinic Followup Note
M-72 Radiation Oncology Followup Note
M-73 Vascular Surgery Clinic Consultation
M-74 General Surgery Clinic Consultation
M-75 Orthopedic Clinic Followup Note
M-76 Initial Colorectal Surgery Consultation
M-77 Internal Medicine Clinic Followup Note
M-78 Orthopaedic Clinic Followup Note
M-79 Hematology/Oncology Clinic Followup Note
M-80 Internal Medicine Clinic Followup Note
M-81 Orthopedic Surgery Hand Team Preoperative History and Physical Examination
M-82 Hematology/Oncology Clinic Followup Note
M-83 Orthopedic Clinic Preop History & Physical
M-84 Emergency Department Treatment Record
M-85 Hematology/Oncology Clinic Followup Note
M-86 Orthopaedic Spine Clinic Consultation
M-87 Emergency Department Treatment Record
M-88 Internal Medicine Initial Visit
M-89 Orthopedics Shoulder Clinic Consult
M-90 Emergency Department Treatment Record
M-91 Internal Medicine Followup Note
M-92 Orthopedic Spine Clinic Followup Note
M-93 Emergency Department Treatment Record
M-94 Internal Medicine Geriatric Clinic Followup Note
M-95 Orthopaedic Hand Clinic Followup Note
M-96 Emergency Department Treatment Record
M-97 Internal Medicine Clinic Followup Note
M-99 Orthopaedic Spine Clinic Followup Note
M-100 Emergency Department Treatment Record
SECTION 2: RADIOLOGY REPORTS
R- 1 CT Brain Scan
R- 2 Bilateral Low-Dose Mammogram
R- 3 Right Breast Mammogram
R- 4 Pain Management
R- 5 MRI, Left Knee
R- 6 Carotid Ultrasound
R- 7 Bilateral Mammogram
R- 8 Right Upper Quadrant Sonogram
R- 9 Acute Abdominal Series
R-10 Ultrasound-Guided Left Hip Aspiration
R-11 Whole Body Bone Scan
R-12 CT, Left Hip
SECTION 3: SURGICAL REPORTS
S- 1 Oromaxillofacial Surgery
S- 2 Orthopedic Surgery
S- 3 Genitourinary Surgery
S- 4 Plastic Surgery
S- 5 Obstetrics/Gynecology Surgery
S- 6 General/Plastic Surgery
S- 7 General Surgery
S- 8 Orthopedics/Plastic Surgery
S- 9 Oromaxillofacial Surgery
S-10 Ophthalmologic Surgery
S-11 Obstetrics/Gynecology Surgery
S-12 Orthopedic Surgery
S-13 Genitourinary Surgery
S-14 Oromaxillofacial Surgery
S-15 Genitourinary Surgery
S-16 General Surgery
S-17 Orthopedic Surgery
S-18 Genitourinary Surgery
S-19 Ear, Nose, & Throat Surgery
S-20 Ophthalmologic Surgery
S-21 General Surgery Report
S-23 Plastic Surgery Report
S-24 Ear, Nose, and Throat Surgical Report
S-25 Obstetrics/Gynecology Surgery
S-26 Gastroenterology Surgical Procedure
S-27 General Surgery Report
S-28 General Surgery Report
S-29 Orthopaedic Surgical Report
S-30 Orthopaedic Surgical Report
S-31 Plastic Surgery Report
S-32 General Surgery Report
S-33 Genitourinary Surgery Report
S-34 Orthopedic Surgery Report
S-36 General Surgery Report
S-37 Orthopaedic Surgery Report
S-38 Obstetrics/Gynecology Surgery
S-39 Genitourinary Surgery Report
S-40 Ear, Nose, and Throat Surgery Report
S-42 General Surgery Report
S-43 Orthopedic Surgery Report
S-44 Ear, Nose, and Throat Surgical Report
S-45 General Surgery Report
S-46 Orthopedic Surgical Report
S-47 Ear, Nose, and Throat Surgical Report
S-49 General Surgery Report
S-50 Orthopedic Surgical Report
S-52 Ophthalmologic Surgery
S-54 General Surgery
S-56 General Surgery
S-58 General Surgery
S-59 Orthopedic Spine Surgery
S-60 Ear, Nose, and Throat Surgery
S-61 Obstetrics/Gynecology Surgery
S-62 Ophthalmologic Surgery
S-63 Genitourinary Surgery
S-64 Vascular Surgery
S-65 Oromaxillofacial Surgery
S-66 General Surgery
S-67 Gastroenterology Surgery
S-68 General Surgery
S-70 Vascular Surgery
S-71 Ear, Nose, and Throat Surgery
S-72 Orthopedic Surgery
S-73 Plastic Surgery
S-74 Obstetrics/Gynecology Surgery
S-75 General Surgery
S-76 Genitourinary Surgery
S-77 General Surgery
S-78 Ear, Nose, and Throat Surgery
S-79 Orthopedic Surgery
S-80 General Surgery
S-81 Genitourinary Surgery
S-82 Obstetrical/Gynecology Surgery
S-83 Nephrology Surgery
S-84 Plastic Surgery
S-85 Ear, Nose, and Throat Surgery
S-86 Genitourinary Surgery
S-87 Orthopedic Surgery
S-88 Obstetrics/Gynecology Surgery
S-89 Plastic Surgery
S-90 Genitourinary Surgery
S-91 Ear, Nose, and Throat Surgery
S-92 Orthopedic Surgery
S-93 Obstetrics/Gynecology Surgery
S-94 Nephrology Surgery
S-95 Orthopedic Surgery
S-96 Ear, Nose, and Throat Surgery
S-97 Obstetrics/Gynecology Surgery
S-98 Genitourinary Surgery
S-99 Orthopedic Surgery
S-100 Genitourinary Surgery
Appendix A Common Dictation Errors
Appendix BThe Joint Commission Official “Do Not Use” List
Appendix CAudio Run Times
Reports by Specialty
Index
System Requirements and Setup Instructions for CD
Single-User License Agreement
Note: The numbers listed in the Table of Contents are not consecutive because some reports (M-8; M-22; M-33; M-35; M-49; M-53; M-58; M-98; S-22; S-35; S-41; S-48; S-51; S-53; S-55; S-57; and S-69) had to be deleted from the final count due to technical difficulties.
Key: M = Medical
R = Radiology
S = Surgical