Learning How To Use Medical Resource Reference Books
Learning
how to use a variety of medical resources is very important. Below is a current
list of books for use as medical references. Here are some examples.
§ Stedman's Medical Speller (Third
Edition)
§ Sloane's Medical Word Book (Fourth
Edition)
§ Taber's Cyclopedic Medical Dictionary
§ Quick Look Drug Book
§ Vera Pyle's Current Medical
Terminology (Eighth Edition)
§ H & P: A Nonphysician's Guide to
the Medical History and Physical Examination
§ Physicians' Desk Reference
§ Medical Transcription: Fundamentals
and Practice (Second Edition)
Introduction
To Medical Transcription:
Proper
Grammar Usage, Punctuation, Capitalization, Abbreviations, Numbers, Numerals,
And Correct Spelling For Medical Terms And Their Plurals
Examples:
Medical
capitalization is routinely necessary for allergies on charting.
ALLERGIES: ALLERGIC TO AMOXICILLIN.
Headings
and subheadings of medical reports are routinely capitalized. Listed below are
some common headings of reports.
§
HISTORY AND PHYSICAL EXAMINATION
§
DISCHARGE SUMMARY
§
CONSULTATION REPORT
§
OPERATIVE REPORT
§
DISCHARGE DIAGNOSIS
Medical abbreviations are used for correct transcription of medication administration.
§
p.r.n. - as needed
§
p.o. - by mouth
§
q.d. - every day
§
q.i.d. - four times a day
§
t.i.d. - three times a day
§
b.i.d. - twice a day
§
q.6h. - every six hours
§
q.8h. - every eight hours
§
q.12h. - every twelve hours
Initials
or abbreviations for some procedures, tests and other medical terms are
important to learn. Below are some
common examples:
§ EKG –
electrocardiogram
§
EEG - electroencephalogram
§
CBC - complete blood count
§
CABG - coronary artery bypass graft
§
AIDS - acquired immunodeficiency syndrome
§
NPO - nothing by mouth
§
HEENT - head, ears, eyes, nose, throat
§
BUN - blood urea nitrogen
§
UTI - urinary tract infection
§
MRI - magnetic resonance imaging
§
CNS - central nervous system
§
PERRLA - pupils equal round reactive to light and
accommodation
There
are proper symbols to use for transcription of vital signs and also sutures.
Examples are listed below.
§
TEMPERATURE: 98.6F.
§
PULSE: 70/min.
§
RESPIRATIONS: 20/min.
§
BLOOD PRESSURE: 130/70.
§
4-0 silk (suture)
§
2-0 chromic suture
§
#16 FR catheter
§
The urine specific gravity was 1.016.
There is a certain way to transcribe numbers and numerals.
Examples:
§
Cranial nerves II-XII were intact.
§
The patient has a 4 cm stage I decubitus ulcer.
§
The patient has 2+ edema in her right ankle.
§
Vision is 20/20 in the right eye.
§
Tylenol #3 q.6h. p.r.n. for pain.
The exact size of an area, growth or mass is transcribed for example: The decubitus ulcer measured 2 x 4 cm.
There are certain abbreviations used for specific laboratory tests.
Examples: Hb-hemoglobin or transcribed hemoglobin
Examples: The
patient was a 52-year-old female admitted with a history of back pain.
The patient was admitted
for right-sided flank pain.The patient went for a chest x-ray.
Learning The Body Systems
Examples:
§
Nervous System
§
Cardiovascular System
§
Respiratory System
§
Musculoskeletal System
§
Integumentary System
§
Endocrine System
§
Urinary System
§
Reproductive System
§
Digestive System
Learning About Diagnostic Medical Test And Procedures Including Laboratory Test And X-rays
Learning The Medical Specialties
§
Psychiatry
§
Internal Medicine
§
Endocrinology
§
Dermatology
§
Gastroenterology
§
Oncology
§
Obstetrics and Gynecology
§
Neurology
§
Radiology
§
Urology
§
Cardiology
§
Pediatrics
Learning Pharmacology Including Brand And Generic Names of Medication And Common Dosages
There
are many helpful medical references to use, such as: Drugs.com and Quick Look
Drug Book, etc.
Learning Correct Formatting And
Transcription Styles
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