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Wednesday, July 29, 2009

Medical Transcription and Dancing.......

You may ask, "What, exactly, does MT have to do with dancing?"

It goes like this. Dr. Ditzy works in an ER near a club. As it turns out, pole dancing is a high-injury activity, and Dr. Ditzy occasionally has to treat the dancers for sprains incurred while arching, grinding, dangling perilously from the ankles and spinning around a pole in 5-inch heels. Most of these pole dancing injuries are minor, but still, mothers, don't let your daughters grow up to be pole dancers; they visit the ER as often as football players from the local high school. It's a treacherous profession. Please, send your daughters to law school instead.

Back to MT...Dr. Ditzy is dictating an ER report on a 21-year-old pole dancer who is in for knee pain. It seems she has (in a highly erotic manner, of course) managed to bang her right knee against the pole during her dance routine and subsequently has come into the ER for an x-ray. Once Dr. Ditzy speaks the words "pole dancer," he suddenly becomes tongue-tied and begins fumbling around for words. This is understandable, and a good MT immediately knows what to do...get a cup of tea and wait. He'll come to his senses in a minute. In the meantime, he continues dictating haltingly and breathlessly whispers a word that sounds like "apree." Deciphering the words of a doctor in such a condition is a skill needed by all MTs.

Since the patient is 21 and the doctor had previously dictated that she is sexually active, and you remember those days very well....Oh, the passion!...you suspect that "apree" might be some kind of contraception.

If your cat happens to be sleeping on your drug book, you might want to search online and see what you can find out about apree. That's where MPR, Monthly Prescribing Reference, comes into play.

MPR lets you search by sounds-like criteria and makes suggestions if you don't spell the word in question correctly, just like Google does. If you type "apree" in the search box, it says, "Did you mean to search for 'Apri' (you idiot)?" And there you have your word. And no, it doesn't accuse you of being an idiot, I put that in there myself. It's just that I felt like an idiot when Apri first came out and I hadn't heard of it yet. It's hard being an MT. We have feelings, you know.

MPR also lets you search by therapeutic category. You can choose OB/Gyn, click on Contraceptives, and a list of OCPs pops up. You can scroll down the list until you find the one that you're looking for.

If you are worried about Dr. Ditzy's condition and are looking for a hypertension drug for him to take after the pole dancer leaves, you can choose Cardiovascular System, click on Hypertension, and a list of hypertension drugs pops up for consideration.

Tuesday, July 28, 2009

Old days.............


1897 - Woodcut of a typist transcribing dictation using an early wax cylinder phonograph, or gramophone. Although the phonograph was first invented by Thomas A. Edison, the source text says this was a machine called the 'G', invented by Alexander Graham Bell, Chichester A. Bell, and Sumner Tainter. The typist pumps the treadle with his foot, turning the cylinder to play back the recording, and listens to it using 'stethoscope' type earphones. Extra wax cylinders, and a mouthpiece used to record dictation, are seen on the desk. Alterations to image: removed caption, which read, "The Gramophone used in transcribing".

Medical Transcription History in Depth

The evolution of the systems dates back to the year 1960 as per Medical Transcription history. The systems in the yesteryears were designed to assist the manufacturing process. The first transcription that was developed in this process happens to be MRP (medical resource Planning) in the year 1975.This was followed by another advanced version namely MRP2 which is the acronym for Manufacturing Resource planning. None of them yielded the benefit of Medical Transcription.

Drawback of MRP Systems
These softwares were helpful in manufacturing process. Their benefits did not extend to other Sectors. Medical Transcription was developed as multifaceted transcription that gradually stretched its limits into other areas like human resource, finance, marketing and so on. Moreover Medical Transcription offered operational convenience and large reduction in costs coupled with other benefits when compared with earlier soft wares.

MRP solutions attained more fame. Infact it became a hallmark of the manufacturing setups.The MRP solutions did not render the expected results due to exorbitant costs and practical work problems.Inaddition it also called for a huge pool of technical expertise in terms of manpower and machines.

Advent of Medical Transcription
Medical Transcription came into being with effect from 1990 though the fact remained that many people are of the opinion that Medical Transcription existed from the year 1960 in the form of MRP1 and MRP2. In fact MRP2 was more or less Medical Transcription except for its inability to coordinate departments other than marketing. The whole period from the year 1960 is denoted as the age of Medical Transcription. The benefit of Medical Transcription was slowly felt from this stage onwards.

Operating Systems
The operating systems that were in vogue during the period are important in understanding the history of Medical Transcription. JD Edwards Co Founder of moniker (in the year 1977) made use of IBM Systems/38.Baan Corporation utilized UNIX.

Web friendly
While Medical Transcription is a technological innovation in itself its efficiency is multiplied by several times with the help of latest inventions. Nowadays Medical Transcription is tuned to make use of the internet. This is to make sure that the buyers anywhere can have access to the database of the seller by a mouse click and that too by sitting anywhere in the world. This has become the mantra in the 21st century. The latest Medical Transcription tool which is becoming the order of the day is Medical Transcription.

Monday, July 27, 2009

Behind the scenes......


I always say that MT is a job for behind-the-scenes people. It's great for those who like to be left alone to work, people who like debating about the proper use of punctuation and grammar, people who like reading, writing, editing...people who enjoy working with words. If you always have a book in your hand, were a spelling bee contestant in school, spent a lot of time in the library, enjoyed English lit in school, MT may be a good choice for you.

If you also have an interest in science, enjoyed biology, chemistry, anatomy & physiology in school, MT may be right up your alley.

Most people don't even know what medical transcription is, let alone what it involves. If they've ever heard of it at all, they probably think of it as "medical typing," which sure sounds easy. I've had people approach me and say they want an MT job because they type fast and it sounds easy, their aunt does it for the family doctor, and it's something they can do in their spare time to make a couple extra bucks. When I explain that they need training first, they often scoff and say something like, "I have an MBA, I don't need training to do typing." But when I have them listen to a sample dictation, they usually slink off, tail between legs. It's not as easy as it sounds.

That said, there are those who have learned it on the job, mostly transcribing easy clinic notes involving runny noses and bellyaches. But if you gave those people a CABG op note to transcribe, they'd be lost. They wouldn't know the terminology, the equipment, or the anatomy. But clinic notes, sure, you can learn that on the job sometimes, especially if you have someone to mentor you. But MT companies want their MTs to be well trained these days. They want to know that an MT can handle transcription involving a cardiac catheterization, endarterectomy, Nissen fundoplication, craniectomy, meniscectomy, or a laparoscopic cholecystectomy. They want to know that an MT knows what words like esophagogastroduodenoscopy and salpingo-oophorectomy mean and how to spell them.

The want to know that an MT can recognize and correct transcription errors, knows how to avoid dangerous abbreviations, knows when to flag inconsistencies, understands HIPAA regulations, and can decipher what the dictator is saying, even one with a heavy accent, when he/she is sneezing, yawning, chewing, or drifting off to sleep while dictating.

Although MT is done behind the scenes and few people understand what it involves, medical transcription is very important in that it must be done correctly to avoid critical errors in patient records...which brings us back to choosing a good MT school. If you're well trained and persistent, MT can really pay off for you.

Friday, July 24, 2009

Pakistan Threatens Indian Grip On Offshore Outsourcing

Pakistan sat quietly as it watched it's Indian neighbors quickly ascended to become the IT outsourcing capitol of the world, however, they were paying attention. Using the same Indian business model, the Pakistani business and economic development community has achieved major successes in carving out their own piece of the lucrative offshore IT outsourcing business. In the global outsourcing market, dominance is hard to achieve for the long haul. As lower wage employees develop highly sought after skills, the cost of retaining these employees leaves companies at an economic disadvantage.

Based on the pure economics of the two countries, it is evident that Pakistani IT companies will outpace Indian companies in the coming years, based on several factors:

India has a developed IT sourcing infrastructure, with established professionals demanding increased salaries. Increased labor expenses for outsourcing solutions makes companies less competitive, unless the output is exceedingly exceptional.

Pakistan has a huge community of émigrés with experience in technology. And like India, it has a culture that values education and hard work. Pakistan, like India, has a large number of English speaking residents.

Pakistan predicts a 45% annual growth in coming years. Although Pakistan IT exports represent only 11% of what India exports, Pakistan is quickly closing the gaps on the lucrative software application development market.

Gartner, in its recent report 'Analysis of Pakistan as an Offshore Service Location' said the major factor behind the progressing status of Pakistan is the lower salaries and better infrastructure advantages than other offshore destinations. "The salaries of IT professionals in Pakistan are approximately 30% lower than those in India, while telecommunication costs are also lower as compared to any other offshore locations, which make Pakistan an attractive outsourcing destination."

The Pakistan government is fully committed to the Pakistani IT initiatives..."According to Gartner research report, government of Pakistan has devised a comprehensive national IT policy, designed to encourage the private sector. In order to drive development, Pakistan Software Export Board (PSEB) plans to construct new IT parks in major cities while 750,000 square feet of space in PSEB-designated parks has already been leased to IT companies."

Monday, July 20, 2009

Funny Medical Transcription Errors with Cartoons


FUNNY ERRORS WITH CARTOONS: Pakistantranscribe's implish cartoons can be printed and posted in a variety of high-impact placed in hospitals and clinical settings. Highly recommended targets are medical transcriptionist's desks, proofreaders' cafeteria and medical transcription rooms.



Cartoon#1


"The patient arrived with death sitting on her shoulder."


Cartoon#2

"Chief Complaint: Motorcycle versus tree."

Cartoon#3

"The greater trochanter was inserted in the abdomen."

Cartoon#4

"There is no swallowing of the left leg."

Cartoon#5 (sorry friends, pic is censored)

"I asked Dr. O, who did her sigmoidoscopy and colonoscopy, to poke his head in and he, too, though that it did not look like a classic colon cancer."

Cartoon#6

"A baby was born in the toilet of the Emergency Department."

Cartoon#7

"The patient was examined with Dr. M under the microscope."

Cartoon#8

"The patient is breathing oxygen through nasal prawns."

Cartoon#9

"When i got into his mouth i could see why he was bleeding."

Cartoon#10

"The patient is concerned about seborrheic keratosis that she has had treated by a dermatologist on her face."

Cartoon#11

"Her weight has increased 8-10 pounds an hour for the last four years."

Cartoon#12

"The hemorrhoid got worse and finally came to the office."

Cartoon#13

"Apparently, she had a boyfriend who died approximately one month ago and at that point began drinking heavily."

Cartoon#14

"The patient's wife hit him over the head with an ironing board, which now has six stitches in it."

Cartoon#15

"He was Beconase nose spray, two sprays in each, one or two in each nose, two to three times a day."

Cartoon#16

"The infant was discharged to home with Mom in car seat."

Cartoon#17

"Chief Complaint: Spinning of head occasionally."

Cartoon#18

"B12 1 cc i am given." should be "B12 1 cc IM given."

Cartoon#19

"Has cafeterias of fall colitis." should be "Has scattered areas of folliculitis."

Funny Medical Transcription Errors with Cartoons-17


Funny Medical Transcription Errors with Cartoons-16


Funny Medical Transcription Errors with Cartoons-15


Funny Medical Transcription Errors with Cartoons-14


Funny Medical Transcription Errors with Cartoons-13


Funny Medical Transcription Errors with Cartoons-12


Funny Medical Transcription Errors with Cartoons-11


Funny Medical Transcription Errors with Cartoons-10


Funny Medical Transcription Errors with Cartoons-9


Funny Medical Transcription Errors with Cartoons-8


Funny Medical Transcription Errors with Cartoons-7


Funny Medical Transcription Errors with Cartoons-6


Funny Medical Transcription Errors with Cartoons-4


Funny Medical Transcription Errors with Cartoons-3


Funny Medical Transcription Errors with Cartoons-2


Funny Medical Transcription Errors with Cartoons-1


Saturday, July 18, 2009

Language Skills Worksheets

Obviously, readers of this blog cannot fill in the blanks on these worksheets by entering data on their computer screens. However, readers should feel free to print out any of these worksheets for use as a teaching/learning tool in a professional setting.

Language Skills Worksheet #1
Doctors frequently use abbreviations, eponyms, and other mnemonic devices as a means of communicating vital patient information. However, each abbreviation can stand for more than one medical term.

Language Skills Worksheet #2
Many people fail to understand that someone in a foreign country who is transcribing dictation from doctors in American hospitals will be thinking in textbook English as opposed to the way English is spoken in America.

Language Skills Worksheet #3
Doctors frequently use the wrong word. This can result in either a grammatically incorrect statement or a raging Malapropism.

Language Skills Worksheet #4
Many doctors dictate in a conversational, stream-of-consciousness style. This habit can result in frequent contradictions and statements which make no sense. Poor sentence structure and improper punctuation, can cause further confusion.

Language Skills Worksheet #5
The constant presence of misplaced modifiers and dangling participles in a doctor's dictation offers a clear indication that the dictating physician suffers from impaired language skills.

Language Skills Worksheet #6
Many doctors suffer from the curse of the run-on sentence.

Language Skills Worksheet #7
Doctors will frequently dictate sentences in which the timing of certain events is suspicious, if not downright impossible.

Language Skills Worksheet #8
Doctors frequently dictate sentences which, although well-intentioned, imply that a person other than the patient is being diagnosed or receiving treatment.

Language Skills Worksheet #9
When dictating reports, doctors are attempting to memorialize certain facts and thoughts in print. If their thought processes involve a rambling, stream-of-consciousness approach to the English language, they are likely to dictate medical gobbledygook.

Language Skills Worksheet #10
Often, when documenting a patient's objective findings, a dictating doctor will use incorrect medical terminology in such a way as to defy anatomical standards.

Language Skills Worksheet #11
Many doctors do not listen to what they say. The results make them vulnerable to charges of practicing "nonsense medicine."

Language Skills Worksheets#1


Doctors frequently use abbreviations, eponyms, and other mnemonic devices as a means of communicating vital patient information. However, each abbreviation can stand for more than one medical term.

Fill in the blanks to see how accurate your dictation would be if the abbreviation you used to communicate your thoughts was misinterpreted by a medical transcriptionist (the figure next to each abbreviation represents the number of meanings listed in Sloane's Medical Abbreviations and Eponyms):


ACE (3)

1.____________________________________
2.____________________________________
3.____________________________________

LP (11)
1.____________________________________
2.____________________________________
3.____________________________________
4.____________________________________
5.____________________________________
6.____________________________________
7.____________________________________
8.____________________________________
9.____________________________________
10.___________________________________
11.___________________________________

MR (10)
1.____________________________________
2.____________________________________
3.____________________________________
4.____________________________________
5.____________________________________
6.____________________________________
7.____________________________________
8.____________________________________
9.____________________________________
10.___________________________________

NAD (5)
1.____________________________________
2.____________________________________
3.____________________________________
4.____________________________________
5.____________________________________

PE (14)
1.____________________________________
2.____________________________________
3.____________________________________
4.____________________________________
5.____________________________________
6.____________________________________
7.____________________________________
8.____________________________________
9.____________________________________
10.___________________________________
11.___________________________________
12.___________________________________
13.___________________________________
14.___________________________________
UA (6)
1.____________________________________
2.____________________________________
3.____________________________________
4.____________________________________
5.____________________________________
6.____________________________________

Language Skills Worksheets#2


A great deal of effort is being spent teaching medical transcription to overseas workers in the hope that, by combining Internet technology with the cheap labor costs available in places like India, the Philippines and the Caribbean, America's largest transcription agencies can increase their profits to shareholders. While this may be a sound approach to take when manufacturing widgets, the improper use of the English language by foreign transcriptionists (as well as by doctors who speak English as their second language) often creates contextual problems.

Many people fail to understand that someone in a foreign country who is transcribing dictation from doctors in American hospitals will be thinking in textbook English as opposed to the way English is spoken in America.
Conversely, one transcriptionist's favorite Indian physician dictates:

"The patient will return to see us when she returns from wacation. She is feeling wery wery good today."

What goes through the mind of a professional medical language specialist when confronted with such dictation?
"The doctor sounds like Elmer Fudd, the guy in the Bugs Bunny cartoons who is always screaming 'I'll get you, you wascally wabbit," laughs the woman who transcribes this doctor's work.The following quotes are taken from people who speak English as a second language. In each situation, rewrite the text so that it is grammatically correct.

"Excuse me, sir but I am not understanding. Why are they serving me all this meat when I have been a vegetable for 20 years?"
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"The patient has no any problems with more or less shortness of breath."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"The patient complains of pain in the left-sided eye."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"I have spoken with Dr. Y and he recommends you service very highly."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"The complications have been fully informed."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"There is no swallowing of the left leg."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"Patient cannot get an election due to he is deplessed."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"Her car was stroked by another car."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"It was a pressure seeing this patient for you."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"I have saw her and evaluated her in the office."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"At the time of the accident, the patient was driving a Dodge Clot."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________

Language Skills Worksheets#3


Doctors frequently use the wrong word. This can result in either a grammatically incorrect statement or a raging Malapropism. Each one of these statements was dictated by a licensed physician.
Diagnose what is wrong with the dictating doctor's statement and write your own version of what the physician failed to communicate.
"I had a blood side glucose done at the bed scene."
Diagnosis: ________________
Corrected Text: _____________
"Temperature was 96 percent."
Diagnosis: _____________
Corrected Text: _____________
"He does live with his wife here in San Francisco and works as a dish water at the XYZ Restaurant."
Diagnosis: _____________
Corrected Text: _____________
"The hand was exsanguinated using an eschar wrap."
Diagnosis: _____________
Corrected Text: ____________
"The patient had diminuted pulses."
Diagnosis: _____________
Corrected Text: _____________
"The patient received a definite hernia repair."
Diagnosis: _____________
Corrected Text: _____________
"The greater trochanter was placed inside the abdomen."
Diagnosis: _____________
Corrected Text: _____________
"Temperature was 96 per minute."
Diagnosis: _____________
Corrected Text: _____________
"The patient reports that following her MBA she developed chest pain."
Diagnosis: _____________
Corrected Text: _____________

Language Skills Worksheets#4


Many doctors dictate in a conversational, stream-of-consciousness style. This habit can result in frequent contradictions and statements which make no sense. Poor sentence structure and improper punctuation can cause further confusion.

Each one of these statements was dictated by a licensed physician. Diagnose what is wrong with the dictating doctor's statement and write your own version of what the physician failed to communicate.

"The patient is now producing a stool specimen here for analysis but most likely this is viral."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"The patient is a 90-year-old whitefemale who states that she was bending over today, putting in a drawer, when she felt her hip pop out."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"The patient came to the EmergencyRoom with a history of vague abdominal discomfort, or chest pain, or neither,or both, lasting for the last several days or not."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"The patient radiated to the right."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"Significant for high cholesterol which is controlled by medication and vasectomy."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"The patient was advised to not lift any heavy weight such as a box of French fries."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"His elevated LDL is here to be discussed."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"Her mother died last May after sixty years of smoking camels."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"A baby was born in the toilet of the Emergency Department."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"The patient had 10-12 diarrhea stools with no flushing."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"Cardiovascular system: There was no murmur noted during hospitalization and perforation was good throughout."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"The patient had some things in her nose and her mother and her sister do, too."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"The patient passed out at work and was found on the floor by his desk."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"The patient was recovered on the ward when she was fully awake, approximately 30 minutes after she woke up."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"Rectal examination was not done because they could not find any lubricant on the floor."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"She complains of no history of injury today or tomorrow, but she maybe sprained her left ankle about a week ago, and is now limping."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"She has no new acute complaints except that she feels somewhat more nauseated than old."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"The patient was taken to the recovery room in good disposition."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"Diagnosis: Questionable history of uterus and cervix."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"Emergency Room Course: The patient was given Maalox 30 cc p.o. with 98% pulse oxygenation on rectal exam."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"Because of some hypocalcemia requiring intravenous supplementation transitorially, she was in the hospital the sixth postoperative day when she was discharged on oral calcium supplements with diet and activity as tolerated."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"Definitely, laparoscopy would be really the only thing that could really help us to really look at this area."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"He had a pacemaker placed in the East Bay for unclear reasons sometime in the last few years."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"So even though her lactate extraction is normal and therefore she doesn't have ischemia, she certainly looks like an ischemic response to morphine and her ST segments would scare the most brave of cardiologists when these changes occur."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"This patient is very fart and smunny."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________

Language Skills Worksheets#5



The constant presence of misplaced modifiers and dangling participles in a doctor's dictation offers a clear indication that the dictating physician suffers from impaired language skills. Each one of these statements was dictated by a licensed physician. Diagnose what is wrong with the dictating doctor's statement and write your own version of what the physician failed to communicate.

"The patient's wound is still inflamed. The drain now looks white and cloudy. I have started her on some Keflex and will send a sample of this over for culture."
Diagnosis:
_____________________________
_____________________________
Corrected Text:
_____________________________
_____________________________
_____________________________
_____________________________
"A recheck of my blood pressure showed her to be 212/150 with a sinus rhythm."
Diagnosis:
_____________________________
_____________________________
Corrected Text:
_____________________________
_____________________________
_____________________________
"I asked Dr. O, who did her sigmoidoscopy and colonoscopy, to poke his head in and he, too, thought that it did not look like a classic colon cancer."
Diagnosis:
_____________________________
_____________________________
Corrected Text:
_____________________________
_____________________________
_____________________________
_____________________________
"Mr. C. is a young man following an injury sustained by the tractor that he was driving on while in an intoxicated state."
Diagnosis:
_____________________________
_____________________________
Corrected Text:
_____________________________
_____________________________
_____________________________
_____________________________
"The gallium scan during her stay was carried up to her son, who was in her head, to rule out the diagnosis of sarcoidosis."
Diagnosis:
_____________________________
_____________________________
Corrected Text:
_____________________________
_____________________________
_____________________________
_____________________________
"This is a delightful man who is well taken care of by his family, whose urine culture was negative and whose blood cultures were negative."
Diagnosis:
_____________________________
_____________________________
Corrected Text:
_____________________________
_____________________________
_____________________________
_____________________________
"I assumed care of this 35-year-old male from Dr. G. at 8:00 a.m., who presented complaining of left lower quadrant pain, onset last evening."
Diagnosis:
_____________________________
_____________________________
Corrected Text:
_____________________________
_____________________________
_____________________________
_____________________________
"During the hospital course the patient was seen in surgical consultation by Dr. D., who showed evidence of periosteal hernia."
Diagnosis:
_____________________________
_____________________________
Corrected Text:
_____________________________
_____________________________
_____________________________
_____________________________
"Mental status examination on admission: She was found in bed with her friend and says through an interpreter that there is difficulty in communication."
Diagnosis:
_____________________________
_____________________________
Corrected Text:
_____________________________
_____________________________
_____________________________
_____________________________
"This 54-year-old female is complaining of abdominal cramps with BMs on the one hand and constipation on the other."
Diagnosis:
_____________________________
_____________________________
Corrected Text:
_____________________________
_____________________________
_____________________________
_____________________________

Language Skills Worksheets#6


Many doctors suffer from the curse of the run-on sentence. Each one of these statements was dictated by a licensed physician. Diagnose what is wrong with the dictating doctor's statement and write your own version of what the physician failed to communicate.

"He states no previous history of kidney stones or kidney problems but he does have a history of recurring episodes of gout in the past and also apparently has had recurrent skin rashes on the penis due to infections passed back and forth between he and his wife."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"However, the reliability of this history is somewhat limited because of the nature of the translations and the question of a clear understanding of what I was asking either on the part of the diplomatic personnel translating for us or the patient's response."

Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"The patient was instructed to hold her Pepcid because she was started on low sex for symptoms compatible with reflux esophagitis that were not treated successfully with Reglan and which caused her diarrhea and Pepcid."

Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"However, he states that his own doctor, Dr. W, has told him repeatedly in the past that he is not paranoid so he was thinking about calling the police on the people but he thinks maybe the police have been talking to the people and that the police were following him around to bust him for narcotics although he doesn't use narcotics, at least he doesn't use narcotics often but did admit to using methamphetamine some unspecified time in the past."

Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"He states however that he has been hospitalized for psychiatric problems within the last several days and since being hospitalized he has stopped drinking for two years, except for that eight days that he fell off the wagon when he came in here on the 19th and that he stopped smoking for the last two weeks and indeed was wearing a Nicoret patch on his right upper arm."

Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"She was apparently seen by her regular physician, Dr. K, who diagnosed flu and put her on Keflex which she started on Wednesday and took Wednesday and Thursday but was feeling bad and went to see her urologist, Dr. J yesterday, who did a urine check on her and felt that she had a urinary tract infection, a kidney infection, and switched her to ciprofloxacin, which she took."

Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________

Language Skills Worksheets#7


Doctors will frequently dictate sentences in which the timing of certain events is suspicious, if not downright impossible.

Each one of these statements was dictated by a licensed physician. Diagnose what is wrong with the dictating doctor's statement and write your own version of what the physician failed to communicate.

"She has been on one liter of oxygensince 1987 continuously."
Diagnosis:
_______________________________
_______________________________
Corrected Text:
_______________________________
_______________________________
_______________________________
_______________________________
"He suggested that the patient should have an enteral crisis of small bowel in 2-3 weeks after things settle down."
Diagnosis:
_______________________________
_______________________________
Corrected Text:
_______________________________
_______________________________
_______________________________
_______________________________
"...overall in the last two months there has now been, in recent weeks, a decrease in overall flow and bleeds lightly for a few days every two weeks most recently."
Diagnosis:
________________________________
________________________________
Corrected Text:
________________________________
________________________________
________________________________
________________________________
"This patient has had two ultrasounds during her pregnancy, one on 06/11/91 when she should have been 8 weeks, 6 days by dates and was 8 weeks, 3 days, with normal fetal heart tones seen on the ultrasound. On 09/23/91, she was 23.7 days by date and 23.5 days by ultrasound. No anomalies were noted."
Diagnosis:
________________________________
________________________________
Corrected Text:
________________________________
________________________________
________________________________
________________________________
"He has a history of incomplete small bowel obstruction and was admitted to the hospital here last on 10/28/90, at which time the condition resolved with placement of a nasogastric tube and did not require previous surgery."
Diagnosis:
________________________________
________________________________
Corrected Text:
________________________________
________________________________
________________________________
________________________________

Language Skills Worksheet#8


Doctors frequently dictate sentences which, although well-intentioned, imply that a person other than the patient is being diagnosed or receiving treatment.

Each one of these statements was dictated by a licensed physician. Diagnose what is wrong with the dictating doctor's statement and write your own version of what the physician failed to communicate.

"Mr. M., who is 70 years old and has significant atherosclerotic coronary disease, was recently admitted to the hospital on the 10th by Dr. W. after he passed out in his cardiac rehab class."
Diagnosis:
___________________________
___________________________
Corrected Text:
___________________________
___________________________
___________________________
___________________________
"The patient is an 84-year-old male who is a patient of Dr. R. who, one day prior to admission, had dental extraction done and used several Tylenol #3 with codeine pills for pain control."
Diagnosis:
___________________________
___________________________
Corrected Text:
___________________________
___________________________
___________________________
___________________________
"The patient is a 69-year-old white female with a past medical history of having sacral decubitus with debridement and excision done by Dr. K., who developed an episode of ventricular fibrillation and was successfully resuscitated postoperatively."
Diagnosis:
___________________________
___________________________
Corrected Text:
___________________________
___________________________
___________________________
___________________________

Language Skills Worksheet#9


When dictating reports, doctors are attempting to memorialize certain facts and thoughts in print. If their thought processes involve a rambling, stream-of-consciousness approach to the English language, theyare likely to dictate medical gobbledygook.

Each one of these statements was dictated by a licensed physician. Diagnose what is wrong with the dictating doctor's statement and write your own version of what the physician failed to communicate.

"This 72-year-old male was discharged from the hospital about a week ago. Since home, he had been doing fairly well as regards his breathing, but for the past few days the wife states she has had trouble moving his bowels and the patient has really not had a good bowel movement since he left the hospital."
Diagnosis:
________________________
________________________
Corrected Text:
________________________
________________________
________________________
________________________
"She states that while driving her car she was broadsided on the right front by another car that ran a red light wearing a seatbelt and shoulder harness apparatus at the time."
Diagnosis:
__________________________
__________________________
Corrected Text:
__________________________
__________________________
__________________________
__________________________
"
This five-year-old....uh, sentences, can't, uh...words can't put together...uh, says words but don't make sentences, uh...the sentences are incomplete but can't make words..."
Diagnosis:
____________________________
____________________________
Corrected Text:
____________________________
____________________________
____________________________
____________________________
"The patient was initially started on ampicillin and ceftazidime for fear of Pseudomonas from toilet bowl water, which he received for a total of seven days."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"The lesion was removed from the right tragus region and from the left helical rim, changing gloves and instruments between the two sides and sending them to the pathologist."
Diagnosis:
________________________________
________________________________
Corrected Text:
________________________________
________________________________
________________________________
________________________________
"At this time, using a #0 Vicryl, the entire cuff was run. The anterior cuff was closed, and the posterior cuff was closed to themselves. The anterior and posterior cuff were not closed together; only the anterior cuff was run by itself, the posterior cuff was run by itself, and the cuff itself was left open."
Diagnosis:
__________________________________
__________________________________
Corrected Text:
__________________________________
__________________________________
__________________________________
__________________________________
"By the way, this man's chart was labeled William, his original report was labeled William, his name is Norman, not William. Forget the name change on William/Norman, because Norman's name is really William but he goes by Norman but legally it is William."
Diagnosis:
____________________________________
____________________________________
Corrected Text:
____________________________________
____________________________________
____________________________________
____________________________________
"Discharged ambulatory with new husband."
Diagnosis:
______________________________________
______________________________________
Corrected Text:
______________________________________
______________________________________
______________________________________
______________________________________

Language Skills Worksheet#10


Often, when documenting a patient's objective findings, a dictating doctor will use incorrect medical terminology in such a way as to defy anatomical standards.
Each one of these statements was dictated by a licensed physician. Diagnose what is wrong with the dictating doctor's statement and write your own version of what the physician failed to communicate.

"She showed good cognitive function without any cognitive functions."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"HEENT exam is completely and entirely normal except for total alopecia and patient is blind."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"Status post left prostatic knee surgery six weeks ago."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"The patient also underwent a left third foot metatarsal head resection."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"Her anal temperature was 98.2 orally."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"Extremities: Speech intact per husband."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"Extremities: Normal. No edema, no jugular venous distention."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"Extremities reveal mild tremulousness but no tongue wag noted."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"The patient had ulnar deviation of the left ankle."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"Pulses absent bilaterally, more so on the right."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"Ear examination: The genitals were......"
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"Neuro is within tact."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"The abdomen was without liver, kidney, or spleen."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"Cardiac: Decreased bowel sounds."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"The patient is alert and cooperative, although asleep."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"The patient was in her right lower quadrant."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"The cervix was noted to be 140 and high."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"The left breast had no skin, contour changes, nipple inversion, or masses palpated."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"Head: Acephalic, atraumatic."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"Patient complains of numbness with standing in the posterior buttocks and low back."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"Neck: Trachea was midline, no hepatosplenomegaly."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________
"He had obvious jugular venous distention in both necks but he was lying horizontally at the time."
Diagnosis:
______________________________
______________________________
Corrected Text:
______________________________
______________________________
______________________________
______________________________