Types of transcribed reports

Medical transcriptionists type a variety of reports. One report type is the Pathology Operative Report.

This particular report type differs from a typical operative report, or "op note," in that during this procedure, a specimen is removed during the operation and sent for pathological examination. "The operative pathology report of the surgical specimen contains a description of the gross and microscopic examination of the surgical specimen."* The specimen might be a tumor or cancerous growth or any other portion of a diseased organ or tissue.

The pathology operative report details "which structures and organs of the body are involved by the tumor. It verifies the primary site of the cancer and describes the extent to which it has spread. Tumor size will usually be stated in the gross description of the surgical specimen. It is usually specified in centimeters."*

The pathology operative report will feature many of the same characteristics of a typical operative report, including the patient's name, date of the procedure, and preoperative and postoperative diagnosis. As noted above, it may also feature diagnoses relating to the pathological findings of the specimen. Finally, the body of the report will detail the surgical procedure performed and findings therein.

*http://training.seer.cancer.gov/module_abstracting/unit03_sec04_part01_page02_patho_rep.html

Medical Term of the Week

taphophilia

Since this is Halloween week, a macabre term seems appropriate.
Taphophilia is an abnormal attraction to graves. From the Greek taphos (grave) and
philos (love).

Red Flags Rule

This is from:

Hospitals encouraged to prepare for Red Flags rule October 24, 2008
Hospitals should make a good faith effort to comply with the Federal Trade Commission’s Red Flags rule as soon as possible, because the deadline for complying with the rule remains Nov. 1, despite the agency’s recent decision (See this at http://www.ftc.gov/opa/2008/10/redflags.shtm) to delay enforcement for six months. Hospitals are likely to meet the rule’s broad definition of “creditor,” requiring them to develop a written identity theft prevention program. Working with outside counsel Hogan & Hartson, AHA has developed a sample policy (link follows below) that hospitals can use as a first step in developing their written identity theft programs. “While it may be appropriate to start with the sample policy, the regulation requires that the program be appropriate for the organization’s size and complexity and the nature and scope of its activities,” said Lawrence Hughes, AHA assistant general counsel. “Each organization must adapt the sample document to address the specific risks they face and to ensure an appropriate and reasonable organizational response to those risks.” The sample policy is not intended to substitute for responsible legal advice. Hospitals should examine the sample document as part of a comprehensive risk assessment.

Link to Red Flags Rule:
http://www.ftc.gov/opa/2007/10/redflag.shtm
Link to sample policy http://www.aha.org/aha/content/2008/document/08redflagsoverview.doc

Career Counseling at AHIMA

Did you know AHIMA offers Career Counseling?

Go to www.ahima.org and login, then go to Schools/Jobs and click on Career Counseling. There you will find access to HIM job resources including Career Assist - an area constructed to help connect AHIMA members with new employment opportunities. You can Post an Anonymous Resume and View Jobs available throughout the U.S.!

Medical Term of the Week

Muscae volitantes

From Latin, literally "flitting flies".
The Latin term for a "floater".
A floater is a translucent speck that floats across the visual field, due to small bits of protein or cells floating in the vitreous.

Types of transcribed reports

Medical transcriptionists type a variety of reports. One report type is the SOAP note. SOAP is an acronym for Subjective, Objective, Assessment, and Plan. Typically a note such as this might be dictated by a doctor in a clinic setting. The doctor would enumerate the patient's complaints or reasons for being seen, then outline what his examination of the patient revealed. That is the Subjective and Objective portion. The Assessment would indicate what his conclusions were, and the Plan portion would detail what steps are needed to rectify the problem, whether further testing is needed, changes in diet or lifestyle, a consultation by a specialist, a diagnostic or surgical procedure, medication, etc. These types of reports can range from one or two sentences under each heading to multiple pages in length.

Medical Term of the Week


Soporific
Sleep-causing.
Hopefully these posts are not having a soporific effect on the reader.

AHIMA Communities of Practice

Did you know you there is a COP for Recent Graduates? Go to www.ahima.org and login, then go to the Communities of Practice (COP) and click Join/Visit Communities. Click on 'R' and scroll down to Recent Graduates to join this COP! This community is for recent graduates of any HIM program to be able to discuss their experiences taking the credentialing exam, finding a job, experiences with their new job, etc.

Medical Transcription equipment

The equipment required to perform Medical Transcription includes a computer, earphones, and a foot pedal (pictured.) The foot pedal connects to the computer and to the software the transcriptionist uses to listen to their dictations. Typically, one presses on the middle of a foot pedal to play the recorded dictation, lifting the foot to stop the playback. The left button on the foot pedal typically rewinds the dictation and conversely the right button will fast forward.

Your Weekly Medical Term

adiaphorous

a-without
diaphoros - difference

In medicine, neither harmful nor helpful.

Credentials for Medical Transcriptionists

Just as graduates from the HIT program can become credentialed through AHIMA, namely RHIT or RHIA, the same applies for Medical Transcriptionists.

Our professional organization, AHDI, offers 2 levels of credentialing: RMT and CMT. These stand for Registered Medical Transcriptionist and Certified Medical Transcriptionist.

AHDI offers a voluntary exam process to qualify for these credentials. The RMT exam is offered to new graduates, or those with less than 1 year experience transcribing. The CMT exam is offered to those with 2 years acute care transcription experience.

Upon graduation from the Medical Transcription Certification Program at HCC, individuals possess the education needed to obtain employment as a medical transcriptionist. However, going on to become credentialed through the AHDI is voluntary, though recommended, as many employers are showing trends of preference towards credentialed transcriptionists.