`
MEDICAL
TRANSCRIPTION
BSBADM303B Produce Texts from Audio Transcription
BSBADM302B Produce Texts from Notes
BSBWRT301A Write Simple Documents
Medical Administration
Training
Jennifer Atkins
www.mediweb.com.au
© Jennifer Atkins
Medical Transcription
Page | 1
Copyright
Copyright © Jennifer Atkins 2013.1
This training manual is copyright under the Copyright Act 1968.
Any third party copyright material included in this publication is attributed.
Jennifer Atkins asserts her ownership of the Intellectual Property contained
in this training manual. All rights are reserved. No part of this publication
may be reproduced, transmitted, transcribed, stored in a retrieval system,
utilised, distributed, or translated into any other language in whole or in
part, in any form or by any means, by any other party whether it be
electronic, manual, photocopying, recording, or otherwise.
Copying without authorisation is illegal.
Disclaimer
Every attempt has been made to ensure this workbook is free from errors
or omissions. However, as an educational resource, all effort should be
made to ensure you seek professional advice before relying on any
statement or fact contained herein. Material in this workbook is current at
the time of writing.
Jennifer Atkins Medical Administration Training
www.mediweb.com.au
© Jennifer Atkins
Medical Transcription
Page | 2
Table of Contents
RESOURCES: HELPFUL WEBSITES ............................................................................. 5
MEDICAL TRANSCRIPTION ....................................................................................... 7
INTRODUCTION ..................................................................................................... 11
WHAT IS MEDICAL TRANSCRIPTION?
12
WHAT ARE YOUR LEGAL AND ETHICAL OBLIGATIONS?
13
CONFIDENTIALITY
13
PRIVACY
14
PATIENT CONSENT
16
WHO OWNS MEDICAL RECORDS?
16
CREATING MEDICAL DOCUMENTS ......................................................................... 19
WHAT ARE THE STYLE AND PRESENTATION REQUIREMENTS? (1.1)
19
EFFECTIVE WRITING TECHNIQUES
20
STYLES FOR LETTER LAYOUT
23
WHAT IS THE PREFERRED LETTER LAYOUT?
26
WHAT ARE THE SIX PARTS OF A MEDICAL LETTER?
27
WHAT IS THE PURPOSE AND REQUIREMENTS OF MEDICAL TEXT? (1.2)
34
DIFFERENT TYPES OF MEDICAL DOCUMENTS
41
ACCURACY IN TRANSCRIPTION .............................................................................. 51
TRANSCRIPTION EQUIPMENT (2.1)
51
THE MAIN SOURCE OF TRANSCRIPTION ERRORS
54
MICROSOFT WORD SHORTCUT OPTIONS
55
AUDIO CONVENTIONS
61
A BASIC GUIDE TO GRAMMAR AND PUNCTUATION
65
UNCLEAR SPEECH AND DICTATION ERRORS (2.2)
71
CLARIFYING MEANING OF DICTATION (2.3)
73
MEDICAL TERMS .................................................................................................... 77
CLARIFY SPELLING OF MEDICAL TERMS (2.4)
77
SEEK CLARIFICATION
77
PRONUNCIATION
79
AUSTRALIAN VERSUS AMERICAN SPELLING
81
MEDICAL ABBREVIATIONS
83
SINGULAR AND PLURAL MEDICAL WORDS
87
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Medical Transcription
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SPELLING WORDS THAT SOUND ALIKE
89
MEDICAL HOMONYMS
92
CORRECTING TRANSCRIPTIONS ............................................................................. 95
CHECK DRAFT FOR ACCURACY (2.6)
95
CHECK DRAFT WITH AUTHOR (3.1)
96
FORMATTING MEDICAL DOCUMENTS (3.3)
98
PROOFREADING SIGNS (3.2)
101
FINAL SELF-CHECK LIST (3.2)
107
WORKING WITHIN DESIGNATED TIMEFRAMES (2.5)
108
FILING DOCUMENTS ............................................................................................ 115
NAMING AND STORING ELECTRONIC DOCUMENTS (3.3)
115
HOW TO STORE FILES ELECTRONICALLY (3.3)
122
PRINTING DOCUMENTS (3.3)
124
APPENDIX A - WORD LISTS FOR THE HUMAN BODY ............................................. 127
APPENDIX B - PRONUNCIATION LISTS .................................................................. 143
APPENDIX C - COMMON SHORTCUT KEYS............................................................ 158
APPENDIX D - MICROSOFT WORD 2003 INSTRUCTIONS ....................................... 161
ANSWERS TO SELF REVIEW QUESTIONS............................................................... 162
ASSESSMENT CRITERIA ........................................................................................ 166
© Jennifer Atkins
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RESOURCES: HELPFUL WEBSITES
Professional Associations and Medical Standards
•
AGPAL Australian General Practice Accreditation Ltd www.qip.com.au
•
Australian Association of Practice Managers www.aapm.org.au
•
Australian Health Practitioner Regulation Agency http://www.ahpra.gov.au/
•
Australian Medical Association (AMA) www.ama.com.au
•
General Practice Computer Standards http://www.racgp.org.au/yourpractice/e-health/cis/ciss/
•
General Practice Registrars Australia www.gpra.org.au
•
Health Services Commission http://www.health.vic.gov.au./hsc/
•
Medical Practice Act
1992 www.austlii.edu.au/au/legis/nsw/consol_act/mpa1992128/s167.html
•
NSW Rural Doctors Network www.nswrdn.com.au
•
Royal Australian College of General Practitioners (RACGP) www.racgp.org.au
•
State and Territory Doctors Health Advisory www.doctorshealth.org.au
Medical and Health Reference sites
•
National vaccine storage guidelines http://www.immunise.health.gov.au
•
Alcohol Awareness
Site http://www.drinkingnightmare.gov.au/internet/DrinkingNightmare/publishing.n
sf
•
Australian Doctor Online Newspaper http://www.australiandoctor.com.au
•
Cancer Screening Government Site http://www.cancerscreening.gov.au/
•
Department of Health and Aged Care www.health.gov.au
•
Department of Health, Victoria http://www.health.vic.gov.au
•
Doctors Reference Site www.drsref.com.au
•
Government Website About Health Issues www.healthinsite.gov.au
•
How Do You Measure
Up http://www.measureup.gov.au/internet/abhi/publishing.nsf
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Medical Transcription
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•
Infection Control Guidelines For a Health
Setting http://www.nhmrc.gov.au/node/30290
•
National Skin Cancer Awareness www.skincancer.gov.au
•
Quit Smoking www.quitnow.info.au
•
Royal District Nursing Service www.rdns.com.au
•
Seniors Reference Site www.seniors.gov.au
Online Medical Dictionaries
•
Medical Dictionary and Abbreviations http://www.betterhealth.vic.gov.au
•
Medical Dictionary http://www.medilexicon.com/medicaldictionary.php
•
Medical Dictionary www.medterms.com
•
Medical Dictionary www.virtualmedicalcentre.com/medical_dictionary.asp
•
Medical Dictionary http://www.mydr.com.au/medical-dictionary
•
Spell Check www.spellex.com/speller.htm
Medical Abbreviations
•
Abbreviations http://www.medilexicon.com/medicalabbreviations.php
•
Acronyms www.drsref.com.au/acronyms
•
Health Thesaurus
http://www.health.gov.au/internet/main/publishing.nsf/Content/healththesaurus.htm
© Jennifer Atkins
Medical Transcription
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Medical Transcription
Includes the following units of competency:
o BSBADM303B Produce Texts from Audio Transcription
o BSBADM302B Produce Texts from Notes
o BSBWRT301A Write Simple Documents
About this workbook
This workbook is designed to assist participants develop skills in audio typing. It
addresses the correct way to present data in documents, and how to transcribe
dictation to produce accurate medical documents.
Recommended for
Persons interested in establishing their career as medical receptionists, medical
secretaries, or medical typists in the medical and allied health field. Audio
transcription is an elective unit in the Certificate III in Business Administration
(Medical) and is a suitable follow on from a medical terminology course, or as a
standalone unit.
Prerequisites
o Basic knowledge of medical terminology
o Experience with Microsoft Word
o Basic computer knowledge and experience
o Keyboarding experience
Other materials required
o Audio dictation equipment and exercises provided by your trainer
o Access to a medical dictionary
© Jennifer Atkins
Medical Transcription
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Learning outcomes
At the end of the workbook particpants should be able to:
o Produce accurate transcription from audio recordings; using correct
spelling, punctuation and grammar
o Format medical letters correctly
o Self-check typed transcripts against an audio recording
Topics
o Prepare for audio transcription
o Medical documents
o Audio conventions
o Australian versus American spelling
o Medical abbreviations
o Singular and plural words
o Spelling words that sound alike
o Proofreading signs
o Formatting medical documents
o Word lists for the human body
© Jennifer Atkins
Medical Transcription
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About this book
This book is suitable for participants in a range of situations, from classroom based
learning to distance education learning.
The book is developed as a step-by-step learning guide. Participants are to
complete each chapter before moving onto the next section. Activities are provided
for you to work through, and once the relevant skills are developed then you can
move on to the next part of the book.
As this contains nationally recognised units, the activities throughout the book will
require you to draw upon your experiences in life, and your simulated experiences
in a medical environment. These exercises form the basis of your learning so you
will develop the skills necessary to meet the required competency for the units.
Competency in the units will be demonstrated through the completion of the
various activities and assessments as determined by your assessor.
Nationally Accredited Qualification: Upon completion of these nationally
recognised units you will be awarded competency in BSBADM303B: Produce Texts
from Audio Transcription, BSBADM302B: Produce Texts from Notes, and
BSBWRT301A: Write Simple Documents.
Accompanying exercise files
The accompanying exercise files features a number of Microsoft Word activities
including:
o Correct letter layout
o Editing
o Formatting
o Proofreading
o Spelling
There are also electronic audio files which can be transcribed into medical letters
and other Microsoft Word documents. These include:
o Letters to specialists, using specialty medical terms
o Radiology reports
o Glossary of words and definitions (dermatology and gastrointestinal)
o Systems of the body
© Jennifer Atkins
Medical Transcription
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Introduction
The accuracy of health records is at the forefront of quality patient care. Accurate
documentation ensures medical records meet the needs of all health care
professionals, especially those who rely on the medical information in shared
medical reports and other health records.
Medical transcription is an essential component in the correspondence between
patients and health professionals. Information may be transcribed and forwarded
to patients, medical doctors, specialists, or allied health providers, such as
physiotherapists.
Successful transcriptionists have good keyboarding skills, quick typing speed,
knowledge of transcription guidelines and procedures, a working knowledge of
medical terminology, good communication skills, sound English, and proficiency in
grammar and punctuation.
Finally, identifying the appropriate style and
presentation for medical information is vital to the professional look of the finished
document.
© Jennifer Atkins
Medical Transcription
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What is Medical Transcription?
Medical transcription is the practice of converting a practitioners voice recorded
dictation into written documentation. Any treatment or procedure which the
patient incurs must legally be documented in their health record. This can include
any of the following:
o
Medical treatments
o
Procedures
o
Diagnostic tests
o
X-rays, CT scans, MRIs
o
Medical reports
o
Workers Compensation reports
o
Operative reports
o
Consultations
o
Discharge summaries
Any time a patient is referred to another practitioner for diagnosis or treatment,
the referring doctor will receive a letter from the specialist to whom they referred
the patient to. The health professional will dictate relevant information onto a
recorder, which is then transcribed into a document (such as Microsoft Word) by a
medical transcriptionist.
A transcriptionist will transcribe the audio file; then edit, format, and forward a
draft of the file to the practitioner. Once it is reviewed and signed by the author, it
is sent to the intended recipient. These medical documents form part of the
patient's medical history.
© Jennifer Atkins
Medical Transcription
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Styles for letter layout
There are three main styles of letter layout for business or medical letters. They are
full block, modified block and indented block styles.
Full block
The full block style of letter layout has a simple design. All sentences start at the left
margin, and no paragraphs are indented.
Leanne Joyce
23 Simpson Street
Campbellfield VIC 3061
Today’s date
Dr Sarah Driscoll
45 Willis Street
Reservoir VIC 3073
Dear Sarah
RE: Audio Transcription
I am a student at Summerhill Medical Institution. I am learning Audio
Transcription using Medical Dictation Software.
I am developing knowledge in how to set out a full block style letter. All the
sentences start at the left margin and no paragraphs are indented. Do you have
any sample medical letters you could forward?
Yours sincerely
Leanne Joyce
Leanne Joyce
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Medical Transcription
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Modified block
Modified block letters display the return address, date, complimentary close, and
signature to the right of the centre of the page. They are typically set up with a tab
stop position at the centre of the page.
Leanne Joyce
23 Simpson Street
Campbellfield VIC 3061
Today’s date
Dr Sarah Driscoll
45 Willis Street
Reservoir VIC 3073
Dear Sarah
RE: Audio Transcription
I am a student at Summerhill Medical Institution. I am learning Audio
Transcription using Medical Dictation Software.
I am developing knowledge in how to set out a modified block style letter. The
return address, date, complimentary close and signature line start at the middle
of the page. All other lines start at the left margin. Do you have any sample
medical letters you could forward?
Yours sincerely
Leanne Joyce
Leanne Joyce
© Jennifer Atkins
Medical Transcription
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Different types of medical documents
A medical transcriptionist may type a variety of documents depending on their job
description. The following documents all have different purposes, and as such are
written and presented slightly different.
You may transcribe documents which include the following:
o
Medical letters to patients
o
Medical letters to fellow doctors
o
Medical reports to specialists
o
Reports for Workers Compensation or the Transport Accident Commission
o
Informal letters to colleagues
o
Meeting agenda
o
Minutes of meeting
o
Memos
o
Records of conferences and meetings
o
List of patient names and details
o
Patient information sheets
o
Training material for staff meetings
On the following pages are samples of some of the above documents.
© Jennifer Atkins
Medical Transcription
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Audio conventions
An author will give you various instructions during their dictation, which are called
audio conventions. Here is a list of common audio conventions.
Author states:
You type:
Bold
Type the next word/heading in bold
Capital heading
Type the next heading in CAPITALS
Capitals
Type the next word in CAPITALS
Close brackets
Type )
Colon
Type :
Dash
Type a dash -
Figures
Type the next word in figures (i.e.
numbers)
Forward slash
Type /
Hyphen
Type -
Initial capital
Type the first letter in Capitals
New line
Press enter once
New page
Start a new page
New paragraph
Press enter twice
Open brackets
Type (
Open quotes / Close quotes
Type “
Paragraph
Press enter twice
Question mark
Type ?
Quote/ Unquote
Type “
Semi-colon
Type ;
Spell out
Type the matter in words and not
numbers or symbols (i.e. & = and;
4 = four)
Stop
© Jennifer Atkins
Type a full stop
Medical Transcription
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Activity 6 – Audio conventions
Doctor Kinsley has dictated the following letters, with
instructions regarding punctuation and grammar. Retype each
letter responding to the doctor’s audio conventions.
Note that commas are usually not dictated, so you will need to add these yourself.
Dear Dr Dodd Re Matthew Anderson DOB 7th of the 12th
1992 This young man has been my patient for the last 4
years stop over that time we have dealt with many organic
and psychological problems stop he has been involved with
a multitude of health providers all working together in a
team care arrangement to help Matthew cope with his
disabilities stop new paragraph apart from his loss of weight
nutrient malabsorption problems attention deficit disorder and hormonal
dysfunction there have also been other issues stop new paragraph it is difficult to
classify Matthews neurological or cognitive dysfunction stop his lack of motivation
and stamina inhibit his ability to complete his studies stop new paragraph I refer
him to you for further assessment to determine the level of neurological
dysfunction stop
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Medical Transcription
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Activity 9 - Punctuate medical letter
Properly punctuate the medical letter below. There are missing full stops, commas,
and other punctuation marks.
Summerhill Medical Centre
384 Wells Street
Campbellfield VIC 3061
Phone 9444 9444
Fax 9444 9449
10 March 2012
Dr Katherine Kelly
235 Germaine Road
Epping VIC 3076
Dear Katherine
RE Master Michael Riddell
Michael has been seen by me today and is under the care of the Royal Childrens
Hospital at present Michael is severely underweight and this is contributing to his
postural hypotension for example his blood pressure drops when he stands for long
periods
On examination Michael is in the top two percentile for height and the bottom five
percentile for weight He appears to be pale and lacking in muscular tone
His testosterone blood tests show deficiencies in levels but this need not contribute
to his weight issues and postural hypotension I have sent him to have full blood
tests to assess the condition of his pituitary thyroid parathyroid thymus and adrenal
gland
I will review him in two weeks when all test results are in
Yours sincerely
Dr Brendan McGuire
Dr Brendan McGuire
Consulting Endocrinologist
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Activity 14 – Australian/English spelling
The following words have been spelt incorrectly. Refer to the
previous table or look up each word in a medical dictionary to
spell each word correctly.
American
English spelling
spelling
American
English spelling
spelling
Fetal
Feces
Color
Flavor
Orthopedic
Gynecologic
Anesthetist
Hematology
Hemorrhoids
Center
Organize
Analyze
Activity 15 - Choose the correct spelling
Choose the correct spelling for the following sentences by circling
the correct terms.
Ted was flushed in [colour / color], due to his [tachycardia / tachykardia].
Jeremy has suffered from [hemorrhoids / haemorrhoids] for two years, and now
has persistent [diarrhoea / diarrhea].
Trish is two years old and is seeing a [pediatrician / paediatrician] due to her
[behaviour / behavior].
Activity 16 - Correct the spelling
Open the Microsoft Word file 'Spelling - Digestion' and correct
the spelling errors. You may use Appendix A - Word lists for the
human body to assist with the correct spelling of digestive
system words.
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Medical Transcription
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Rules for abbreviation use in letters
Spell out in full
When using abbreviations in medical letters or reports, they need to be spelt out in
full the first time they are used, and then they may be used in their abbreviated
state. For example:
Christine has experienced Chronic Fatigue Syndrome (CFS) since 2001. Her early CFS
symptoms were severe fatigue, poor sleep patterns and depression.
Multiple meanings
If there is more than one accepted meaning for an abbreviation, and there could be
a misinterpretation of the intended meaning, then spell the abbreviation out.
For example:
"Johnathon - DOA February 20, 2012."
Edited version:
" Johnathon's date of admission was
February 20, 2012."
Note that DOA could mean date of admission, date of appointment, dead on arrival,
or date of accident. Thus it is important to read your transcription to determine if
the correct meaning of the abbreviation can be determined by the context.
Chemical abbreviations
In medical letters and reports chemical abbreviations are not substituted for the
written word. They are spelt out in full. However, in pathology reports they are
written in their abbreviated form. For example:
"Heather's pathology report showed
a high BSL of 16 mmom/l."
Edited version:
"Heather's pathology report showed a
high blood sugar level of 16 mmom/l."
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Medical Transcription
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Spelling words that sound alike
Many words sound similar but have different spelling and dissimilar meanings.
These words are called homonyms; which are words that are spelt or pronounced
alike another, but of different meaning. These words can trick your spell check.
Following are the most common words that sound alike.
Similar
Words
Accept,
Except
Advise,
Advice
Affect,
Effect
Conscious,
Conscience
Lead, Led
Their,
There,
They're
We're,
Where,
Were
© Jennifer Atkins
Meanings and examples
Accept is a verb meaning to receive or to agree:
Doctor Saunders accepted their gift.
Except is a preposition meaning “all but those mentioned”:
Everyone went to the doctor except Samuel.
Advise is a verb that means to recommend:
I advise you to be careful with your new plaster cast.
Advice is a noun that means an opinion about what could be done:
Doctor Jean, I'd need your advice on this matter.
Affect is a verb meaning to influence:
Will lack of preparation affect your surgery?
Effect is a noun meaning result:
Will lack of preparation have an effect on your surgery?
Conscious is an adjective meaning awake or aware: The patient
remained conscious throughout the procedure.
Conscience is a noun meaning the sense of right or wrong: Johnny
wouldn't defraud Medicare because his conscience wouldn't let him.
Lead is a noun referring to a metal: The patient had lead in their
body.
Led means to direct: The patient led the Doctor on a wild goose
chase.
Their is a possessive pronoun meaning belonging to them:
They got their medication.
There means that place or position: The medical practice is over
there.
They're means they are: They're preparing the plaster for the
patient.
We're means we are: We're able to assist.
Where means place: Where are you going?
Were is a past tense of the word ‘be’: They were walking to the
clinic.
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Activity 20 – Spelling words that sound alike
Read the following report, which displays all listed words from
the previous table. Cross out the incorrect word and circle the
correct word for each set of brackets.
Thank you for referring this very pleasant 70-year-old woman.
She has a history of joint problems for over 10 years, which has been getting
progressively worse. She had a right hip replacement last year, but is
[conscious/conscience] that she has been left with chronic hip pain. This has the
[affect/effect] of pain in her knees and feet. Her joints ache all the time, especially
at night and often prevent her from sleeping.
She has had two previous back operations and has severe Grade-3 degenerative
disc disease. She has been found to have a calcium deposit on her left knee, and
[lead/led] in her joints.
She is taking glucosamine and chondroitin sulfate and [their/there/they’re]
providing minor relief. She takes an Aspirin daily but finds this upsets her stomach.
Medications have been helpful, [accept/except] anti-inflammatories have been
used unsuccessfully.
Current medications include Gaviscon, and Losec. She has been taking Calcitrate
and is on her third cycle, but is finding little benefit. My [advise/advice] is that she
take Calcitrate every second day and alternate with Aspirin. [we’re/where/were]
here to help in any way we can, which is comforting to Mrs. Jones.
Activity 21 - Common homonyms (see list on following page)
Choose the correct word for each sentence.
1.
The medical practice has purchased a [devise/device] to help patients chart
their own health statistics.
2.
Doris has [lose/loose] bowel motions.
3.
John will have an x-ray [preceding/proceeding] has operation.
4.
In the [coarse/course] of Jackson's treatment he [made/maid] his target
[wait/weight].
© Jennifer Atkins
Medical Transcription
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Medical homonyms
Axillary
Pertaining to the
Auxiliary
armpit
Osteal
Additional; Giving
help
Bony
Ostial
Pertaining to an
opening
Palpation
Examining by touch
Palpitation
(i.e. with the hand)
Perfusion
Passage of fluid
Increased rate of
heartbeat
Profusion
Excess, surplus
Peritoneal
The lining around the
through a tissue
Perineal
The perineum (region
between anus and
abdominal cavity
scrotum or vulva)
Prostrate
Lying face
Prostate
downwards
Gland in male,
surrounding the neck
of the bladder
Pleural
The covering of the
Plural
lung and lining of the
Denoting more than
one
thorax
Prescribe
Advise on the use of
Proscribe
To forbid a practice
Cirrhosis
Chronic liver disease
medicine or
treatment
Psoriasis
Chronic skin disease,
with red scaly patches
Reflex
An involuntary action
Reflux
A backflow of liquid
Stasis
Stoppage of flow of
Staxis
Haemorrhage
Urethra
Tube that conveys
blood or body fluid
Ureter
Vesical
Tube that conveys
urine from kidney to
urine from bladder to
bladder
outside the body
Pertaining to the
Vesicle
bladder
© Jennifer Atkins
A small sac
containing liquid
Medical Transcription
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Self-Review
Medical Terms - True and False Questions
Clarify spelling of medical terms
1. Clarification may be sought by medical books or
medical dictionaries
2. All online medical dictionaries are American based,
and therefore must be avoided when transcribing
3. Microsoft Word spell check will be a most helpful tool
when transcribing medical terms
True or False
Pronunciation and spelling
4. Phonetic spelling, spells out a word as it's
pronounced
5. American spelling omits an 'o' or an 'a' in many
medical words
6. In American spelling, oesophagus is correct, and
esophagus in incorrect
7. In American spelling, diarrhea is correct, and
diarrhoea is incorrect
Medical abbreviations
8. Abbreviations are a form of medical shorthand
9. PR means per receipt
10. TTD means three times daily
11. BD means both days
Singular and plural words
12. A singular word ending in an "a", will have a plural
form of "as"
13. The plural of "aces" has a singular form of "ax"
14. The singular word adenoma has a plural form of
adenomata
15. The plural of bronchus is bronchi
16. The plural of virus is viri
Spelling words that sound alike
17. Accept is a noun that means to receive
18. Affect is a verb meaning to influence
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Medical Transcription
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Medical Transcription
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Proofreading exercise 1
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APPENDIX A - Word lists for
the human body
There are many systems in the body. However, the main systems of the body are:
1. Integumentary
2. Skeletal
3. Muscular
4. Digestive
5. Cardiovascular
6. Respiratory
7. Nervous
8. Endocrine
9. Lymphatic
10. Urinary
11. Reproductive
The following word lists provide common words for each of the systems of the body, plus
radiology and pathology.
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Integumentary system
The integumentary system consists of the skin, its glands, hair and nails.
The skin is considered the largest organ of the body. This is because the
surface area of the skin on an average adult is 2 m2 and represents 16%
of the body’s total weight. The skin functions as a protective covering
for the underlying tissues, and regulates body temperature among other
functions. It consists of two main layers, the dermis and epidermis. The
epidermis is the most outer layer of the skin. The dermis is the second
layer of the skin. Its main purpose is to sustain and support the
epidermis.
Acne rosacea
Epidermis
Onychomycosis
Acne vulgaris
Erbium laser
Pacinian corpuscle
Albinism
Erythema
Paranychia
Alopecia
Follicular Papules
Pigmentation
Angioma
Folliculitis
Prickly heat
Atopic dermatitis
Hair erector muscle
Pruritus
Basal cells
Hair follicle
Psoriasis
Benign
Hair shaft
Pustule
Biopsy
Herpes zoster
Rosacea
Blister
Hyperpigmentation
Salicylic acid
Blood vessels
Impetigo
Scabies
Boil
Inflammatory
Scar
Candidiasis
Integumentary
Sebaceous gland
Carbuncles
Keratosis
Seborrheic keratosis
Carcinoma
Keratotic
Squarmous
Cellulitis
Lice
Subcutaneous
Cold sore
Lichenification
Sweat gland
Collagen
Lipomas
Tinea
Cryotherapy
Liquid Nitrogen
Tretinoin
Cutaneous
Malignant
Verruca vulgaris
Cyst
Melanocytes
Vesicle
Dermatitis
Melanocytic
Vitiligo
Dermatofibroma
Melanoma
Hydroquinone
Dermis
Melasma
Hydrocortisone
Dermoid cyst
Moles
Wart
Eczema
Nodule
© Jennifer Atkins
Medical Transcription
Page | 128
Skeletal system
The skeletal system includes the bones and joints of the body. The bones
are the framework that the body is constructed around. It protects and
supports the body, and assists the muscles with movement of the body.
The skeleton consists of 208 bones in adults, and consists of the axial
skeleton (bones of the head and torso) and the appendicular skeleton
(bones of the arms and legs).
Annular bulge
Facet joint
Occipital
Anterolisthesis
Femur
Osteoarthritis
Appendicular
Fibula
Osteomalacia
Arthritis
Foramen
Osteophyte
Articular process
Foraminal stenosis
Osteoporosis
Articulation
Fossa
Palatine
Axial skeleton
Frontal
Paraspinal
Bilateral pars defect
Gout
Parietal
Broadbased disc
bulge
Greenstick fracture
Patella
Head
Phalanges
Humerus
Process
Impacted fracture
Radiculopathy
Kyphosis
Radius
Labyrinth
Rheumatoid arthritis
Lacrimal
Rib cage
Listhesis
Rickets
Lordosis
Sacroiliac
Lumbar
Sacrum
Lumbosacral
Scapula
Malleolus
Scoliosis
Mandible
Spondylolisthesis
Maxilla
Spondylosis
Meatus
Simple fracture
Metacarpus
Sinus
Metaphysis
Sphenoid
Metatarsus
Spine
Nasal
Sternum
Canal
Canal stenosis
Carpus
Cervical
Clavicle
Coccyx
Comminuted
Condyle
Coxal (pelvic girdle)
Cranium
Crest
Degenerative
Diaphysis
Disc desiccation
Epicondyle
Epiphyseal plate
Epiphysis
© Jennifer Atkins
Medical Transcription
Page | 129
APPENDIX B Pronunciation lists
In this guide the pronunciation is provided after each word. Words of two or
more syllables are broken up with a hyphen (-). The syllable that is stressed is
shown in capitals.
Medical terms are provided for the various systems of the body. Commonly used
terms are provided in each category, followed by the phonetic spelling and
meaning of each word.
For example:
Cardiac is pronounced
KAR-di-ak
Cardiologist is pronounced
KAR-dee-OL-oh-jist
Gastroenteritis is pronounced
gas-troh-enter-I-tis
Gastropathy is pronounced
gass-TROP-uh-thee
Gastrotomy is pronounced
gass-TROT-omi
© Jennifer Atkins 2012
Medical Transcription
Page | 143
Many words are pronounced as they are spelt, but there are exceptions. For
example:
Ch is sometimes pronounced as an k Chronic (KRON-ik)
Ps is pronounced as an s
Psychologist (sy-KOL-o-jist)
Pn is pronounced as n
Pneumonia (new-MOH-nia)
Ph is pronounced as f
Phobia (FOH-bia)
Rh is pronounced as r
Rheumatism (ROOM-a-tism)
Pt is pronounced as t
Ptosis (TOH-sis)
Oe is pronounced as ee
Oesophagus (ee-SOF-a-gus)
Ae is pronounced as ee
Anaemia (a-NEE-mia)
© Jennifer Atkins 2012
Medical Transcription
Page | 144
Integumentary System
Word
Pronunciation
Meaning
Alopecia
al-ǒ-PEE-shiǎ
Hair loss, particularly from scalp.
Dermatitis
der-mǎ-TY-tis
Inflammation of the skin.
Dermatofibroma der-mǎ-toh-FI-bro- mǎ
Small, red/brown bump in the skin.
Dermatologist
A specialist who studies diseases of the
der-mǎ-TOL-ŏ-jist
skin.
Eczema
EKS-imǎ
A recurring, non-infectious,
inflammatory skin condition.
Eosinophil
ee-oh-SIN- ŏ-fil
A white blood cell that can stain
orange-red.
Epidermis
epi-DER-mis
The outer layer of the skin.
Erythrocyte
i-RITH-roh-syt
Red blood cell.
Integumentary
in-TEG-yoo-men-tǎ-re
The skin, hair and nails.
Keratosis
ke-rǎ-TOH-sis
A horny overgrowth of the skin.
Melanocyte
MEL-ǎ-noh-syt
Cells that produce pigment.
Onychomycosis
on-i-koh-my-KOH-sis
Fungal infection of the nail.
Psoriasis
sŏ -RY-ǎ-sis
A chronic skin condition with inflamed,
red, raised areas and silvery scales.
Rosacea
roh-ZAY-shiǎ
A common skin condition with redness,
pimples, and broken blood vessels.
Subcutaneous
sub-kew-TAY-nius
The deepest layer of skin.
Xeroderma
zeer-oh-DER-mǎ
Dryness of the skin.
© Jennifer Atkins 2012
Medical Transcription
Page | 145
Skeletal System
Word
Pronunciation
Meaning
Cervicothoracic
SER-vi-ko-tho-ras-ik
The neck and thorax region.
Coccyx
KOK-siks
Tailbone; four small bones.
Intervertebral
in-ter-VER-te-brǎl
Relating to between the vertebrae.
Lumbosacral
lum-BOH-say-krǎl
Relating to the lumbar vertebrae
and sacrum.
Osteoarthritis
osti-oh-arth-RY-tis
Degenerative joint disease.
Osteoporosis
osti-oh-por-OH-sis
Loss of bone tissue.
Phalanges
fǎ-LAN-jeez
Finger, thumb and toe bones.
Scoliosis
skoh-li-OH-sis
Lateral (sideways) deviation of the
spine.
Spondylolisthesis
spon-di-loh-LIS-thi-sis
Shifting forward of a vertebra.
Spondylopathy
spon-di-LOP-ath-e
Disease of the vertebrae.
Spondylosis
spon-di-LOH-sis
Degeneration and flattening of
intervertebral discs.
Thoracolumbar
thor-ass-o-LUM-bar
Relating to thoracic and lumbar
vertebrae.
© Jennifer Atkins 2012
Medical Transcription
Page | 146
Answers to Self Review Questions
Introduction - True and False Answers
What is medical transcription
Qn
Answer
1
True
2
True
3
True
4
False
Legal and ethical obligations
5
False
6
True
7
True
8
False
9
False
Privacy
10
True
11
False
12
True
Your results
..... /4
..... /5
..... /3
Retaining patient records
Qn
Answer
13
False
14
True
15
False
16
False
Health Records Act
17
False
18
True
19
True
20
False
Patient Consent
21
False
22
False
23
False
24
False
Your results
..... /4
...../4
...../4
Total
....../24
Creating Medical Documents - True and False Answers
Style and presentation requirements
Qn
Answer
Your results
1
False
2
True
3
False
4
False
5
True
6
False
7
True
8
True
..... /8
Full block letter layout
9
True
10
False
11
True
12
True
13
False
14
True
..... /6
Medical letters
Qn
Answer
Your results
15
True
16
True
17
False
18
True
19
True
20
False
21
False
...../7
Understanding the purpose of the text
22
True
23
True
24
False
...../3
Types of medical documents
25
False
26
True
27
True
...../3
Total
© Jennifer Atkins 2012
Medical Transcription
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