medical Transcription Styles and Formatting

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In expanding to learning the unique language used by healing professionals, a healing transcriptionist must also be an expert on English grammar and spelling. As if that isn't enough to remember, there are styles and formats that are unique to the healing field; not being well-known with these standard guidelines can originate quality assurance issues for a transcriptionist and the healing records and impact sick person safety.

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Medical Homonyms

Homonyms are difficult for many English speakers to master, but when they occur in healing language, it becomes even more tricky. For example: ileum and ilium. These are healing terms that refer to two dissimilar anatomical areas. In order to go for the exact spelling, it's critical to be well-known with the anatomy and to look at the context in which the word occurs. Experienced transcriptionists create a principles of mnemonics that help them in finding the exact spelling of a homonym.

The ilium is a bone in the pelvis; in lay terms, the hip bone. The ileum is part of the small intestine. An easy mnemonic is to remember that both hip and ilium have the letter "i". After that, a transcriptionist needs to look at the context of the word use in order to apply the standard term and spelling.

Although not determined homonyms, there are terms that sound like something else entirely, resulting in a transcription error, normally by an inexperienced transcriptionist. "Below knee amputation" is frequently mistaken for "baloney amputation." An experienced transcriptionist knows that there is no such thing as a "baloney amputation," regardless of whether or not it sounds like that is what a dictator is saying! In healing transcription, these are referred to as "sounds-like" errors.

Abbreviations

Abbreviations are very common in healing terminology. They allow physicians and other healthcare professionals to document records quickly. Unfortunately, there are many terms that can apply to one abbreviation, which can lead to mistakes. The create for Safe Medication Practices (Ismp) has published a list of terms and abbreviations that can be misread and advised that these be written or transcribed in exact ways in order to avoid confusion.

In healing terminology, the abbreviation Od or o.d. Can be whether right eye - or once daily. It's critical for a healing transcriptionist to know that the Ismp recommends that neither abbreviation be used, that it be written out as "right eye" or "daily," as appropriate.

Abbreviations may also be misread, as one letter closely resembles another, even in a typewritten report. The Ismp also recommends that the abbreviation "Iu" (International Units) not be used, as it can be mistaken for "Iv" (intravenous).

There are also guidelines governing abbreviations for measurements. The use of the abbreviation "cc" (cubic centimeters) is common, but not advised; documentation specialists are advised to use the abbreviation "mL" (milliliters) instead, as "cc" can be misread.

Documenting for accuracy and clarity

The core guidelines for healing transcription style and format are geared towards documenting the narrative with accuracy and clarity so that other healthcare professionals can absolutely find and read the facts they need to make healthcare decisions, while feeling confident that the narrative is exact insofar as the transcriptionist is able to elaborate the dictator's spoken word and intent.

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