General Surgery and Gastrointestinal System Dictation
Guidelines for Transcription:
General Surgery and Gastrointestinal System Dictation
by Ellen Drake, CMT, AHDI-F
Linda Campbell, CMT, AHDI-F
The SUM Program General Surgery and Gastrointestinal System Transcription Unit was developed to meet the growing demand for quality training in medical transcription. It contains approximately 4-1/2 hours of authentic physician-dictated gastrointestinal (GI) system and general surgery reports, professionally edited to delete confidential information. The dictations in this unit provide comprehensive coverage of the entire GI tract from esophagus to rectum, as well as a variety of surgical reports that would be carried out by a general surgeon. Reports have been carefully selected for vocabulary density and include regional and foreign accents. The reports are first grouped by report type or content and within each group of reports sequenced in a graduated easy-to-complex fashion to maximize learning.
The General Surgery and Gastrointestinal System Transcription Unit will help prepare students for entry-level employment in an acute care setting and is well suited for self-starters in independent home study, for classroom instruction, and for on-the-job training in hospitals, clinics, transcription services, and medical group practices.
A total of 70 medical and surgical reports is offered. The nonoperative reports include history and physicals, consultations, and discharge summaries. Within each grouping, the reports are sequenced from easier to more difficult. The operative reports are grouped as follows: Vascular Access/Port Placement; Abdominal Wound Revision and Herniorrhaphy; Appendectomy; Cholecystectomy; Liver & Spleen Procedures; Head & Neck Surgery; Chest Wall Surgery, Breast Surgery, and Abdominoplasty; GI Upper and Lower Tract Surgery. Again, within each grouping, the reports are sequenced from easier to the more difficult; vocabulary density and difficulty level increases as well throughout the operative groupings themselves.
Accompanying each dictation is an accurate transcript with footnotes explaining edits and, where necessary, content. Ancillary material includes “Gut Reactions: Sorting Out IBS and IBD,” by John H. Dirckx, MD. Two articles written in 1989 and part of the first edition of the Gastrointestinal Transcription Unit are also included here because they are still relevant, informative, and interesting today: “A Surgeon’s View of Gastroenterology and Practice” by Thomas L. Largen, MD, and “Transcribing Gastroenterology Dictation” by Bron Taylor. A Quick-Reference List of General Surgery/Gastrointestinal Words and Phrases concludes the ancillary material.
A new feature is the inclusion of a series of audio soundalikes exercises, provided as individual clips (accessible when the instructor password is entered) for upload to a learning management platform and in four audio files (20 clips each for the first three exercises and 23 clips for the fourth). Both formats lend themselves to incorporation within an online learning management system for automatic grading. The soundalikes are provided at the beginning of the dictation but may be completed at any point in the course. Instead of a blank document opening, when the student clicks on a soundalike exercise, the text with a blank for the soundalike appears, and the student can transcribe the missing word (this is ideal for automatic grading). The transcript keys may be enabled if the instructor wants students to check their own work, or the student can e-mail the assignment to the instructor.
Introduction to General Surgery/Gastrointestinal (GI) Transcription
A standard English dictionary is paramount. Basic medical references recommended include Dorland’s Medical Dictionary or Stedman’s Medical Dictionary, Vera Pyle’s Current Medical Terminology, a current edition of Saunders Pharmaceutical Word Book by Ellen and Randy Drake, and The Book of Style for Medical Transcription, third edition. Other useful references include H & P: A Nonphysician’s Guide to the Medical History and Physical Examination and Human Diseases, both by John H. Dirckx, M.D., and published by Health Professions Institute.
Transcription Technique
Meaningful Text. What is medical transcription? Medical transcription is an interesting skill that few people—even many of those who hire MTs or are MTs—truly understand. Many people think medical transcription is basically a physical skill, that is, typing or keyboarding. And that's part of it, a very small part. However, even the physical aspects encompass much more than hitting the correct keys on a keyboard because properly equipped MTs are also operating a foot pedal, which has a forward, fast forward, and reverse. Because they sit for long hours, MTs must be cognizant of their posture and their physical environment. But none of this comes close to describing what MTs actually do with their brains!
The transcriptionist listens to the spoken word, which can be marked by poor grammar and usage, disorganization, back-tracks, nonlanguage vocalizations, misspeaks, corrections, variable voice volume, and variable speed sometimes approaching Mach 2. The brain must interpret and translate these sounds, which pretty much correspond to a foreign language, into meaningful text (while it continues to control the fingers on the keyboard and the foot on the pedal and keep the body in an ergonomic position).
While interpreting the spoken word into meaningful text, the MT is also organizing, formatting, and paragraphing the text; applying grammar, punctuation, spelling, and style rules; correcting usage; and making sure that the finished report meets the specifications of the dictator or client. In addition, he or she is proofreading on-screen what has just been transcribed, while transcribing what was just heard and listening to the next set of sounds.
Essentially, the brain is performing multiple intellectual functions along with several physical functions. We can think of no other activity or skill that requires such intense mental processing, physical involvement, and concentrated focus of the participant (the MT).
Learning medical language is akin to learning a foreign language. Indeed, it contains many foreign words and phrases, primarily but not limited to expressions of Latin or Greek origin. Medical dictation also contains many abbreviations, brief forms, shortcuts, jargon, medical vernacular, and word coinages that are an integral part of the language of medicine. Because medical reports are dictated, their tone and style are often informal, even conversational.
Occasionally you may encounter a dictation that seems too challenging for you at the moment. Sometimes, especially with repetitive sections of a report like the review of systems, the physical examination, and the opening and closing sections of operative reports, it may take several MTs transcribing the same type of report by the same dictator before they can decipher all the words and phrases that are difficult to hear. Even good dictators may rush through routine sections of a report, and difficult dictators definitely become easier the more often you transcribe them. For that reason, we have purposely included multiple dictations by the same dictators for this unit.
Each time the physician dictates, different words will be clearer. On the job, practitioners often have access to templates or “normals” and “boiler-plate” paragraphs that help them decipher difficult dictators. As a student, you too can begin to create similar “normals” and “boiler-plate” paragraphs. As you identify difficult passages for a particular voice, make a note of it. When you hear that dictator again, dictating a similar passage, you should be able to decipher a bit more than you did on the previous attempt. Relistening to and retranscribing difficult dictation will also help you build skill in deciphering hard-to-understand phrasing.
The transcription of healthcare documents (medical or technical writing) differs in technique from the production of essays and manuscripts (formal writing). With the latter the writer often generates several draft copies before arriving at a finished polished document. There is no time in the production environment for an MT to accomplish the process described above in a stepwise fashion or to “polish” a document. In the workplace, it is simply not feasible or necessary for the production-oriented medical transcriptionist working in a fast-paced environment to attempt to convert a medical document into a piece of formal writing.
During your training, however, is the time to take advantage of all the luxuries you won’t have when you are on the job: the luxury of extensive research, not just for words themselves but background information so that you understand what is going on in the report; the luxury of transcribing a report more than once so that you can learn to identify repeated words and phrases and anticipate what’s coming next, building speed and accuracy through this process; the luxury of proofreading—multiple times, with and without the audio and by just reading the report aloud to yourself.
Your ultimate goal is to produce a first-time final copy without the use of a draft copy. The standard of quality you are striving for is that which you will produce in your future employment as a medical transcriptionist—a neat, accurate, and complete report that may be placed in the patient’s medical chart as a permanent record of healthcare. However, this is just the beginning. Keep your goal in mind but don’t get discouraged as you begin to transcribe. Do, however, strive to prepare a document that is free of wrong words and misspellings, that is, a report that is “chartable.” Make your goal “the right word, correctly spelled, in the right place.”
The first step. Before you begin transcribing, ascertain that your equipment is in proper working order. Assemble your reference books, gather your papers and supplies together, and isolate yourself from frequent interruptions.
It is important to read the introductory articles and to review the table of contents to gain an understanding of the types of reports you will be encountering. If you are given passwords to the transcript keys, briefly leaf through the transcripts so you will know how to set up the various formats.
Building a foundation. The reports in the General Surgery and Gastrointestinal System Transcription Unit are sequenced within each grouping of reports so that your terminology foundation builds as you advance to the next report as well as to the next group of reports. Plan to transcribe each report more than once, until you become thoroughly familiar with its terminology and competent in its transcription. Each transcript should be carefully proofread, with and without the audio, and corrections noted. After proofreading, you should transcribe (not copy-type) a final error-free copy, suitable for charting.
First, listen to each report, paying attention to the dictator’s tone and rhythm and any unusual speech characteristics or accent. Does the dictation flow or is it choppy? Does the dictator seem organized or does he or she stumble around and make a lot of corrections?
Pace yourself. First, listen to each report, paying attention to the dictator’s tone and rhythm and any unusual speech characteristics or accent. Does the dictation flow or is it choppy? Does the dictator seem organized or does he or she stumble around and make a lot of corrections? Make note of words you don’t know and look them up. Then, transcribe each report carefully, stopping as often as necessary to look up new and unfamiliar words for spelling and meaning.
The medical transcriptionist on the job encounters difficult terms as well. When presented with a questionable word or finding, the practitioner has several options: (1) Seek another transcriptionist’s opinion. (2) Refer to the patient’s chart, if available. (3) Contact the dictating physician to ask what was dictated. (4) Leave a blank in the report and flag it to the dictator’s attention. While you may not have access to these remedies as a student, you may want to confer with your instructor, acquire a mentor (the Association for Healthcare Documentation Integrity, AHDI, has a mentoring program for students), or consult with your classmates.
If you fail to locate a word in your reference materials, it could be that the word in question has an initial letter other than the sound you hear. For instance, the phonetic pronunciation of v sounds very much like that of f or b, the letter m may sound like n, and so on. Some letters share the same sound. The z sound you hear may actually be an x (xiphoid) and the k might be ch (ischemic). Medical terms that contain silent letters (gnathic, tachyarrhythmia) also present a challenge.
You can also use the Internet to conduct background research through sites like eMedicine.com or PubMed.com, perform context/phrase searches using Google, and find actual sample medical reports with similar content on medical student and transcription forum sites. Caution: If you use the Internet for research, you must be able to judge the accuracy of the content. See the article by Ellen Drake, “Searching the Wild, Wild, Web” in ePerspectives issue 57: May 2009, on the HPI Web site (http://www.hpisum.com).
As you gain experience utilizing available resources, you will become familiar with the techniques of determining soundalikes and efficient in locating the appropriate terms.
You may find that you are unable to understand a word the first time you encounter it, or you may not be able to find it in your references. When this is the case, leave a blank (or blanks) and continue with the transcription. The dictator may use the word in question a second time, enabling you to determine the appropriate term, or context clues may eventually help you decipher the term.
When you have finished a report, go back and listen to the dictation again while proofreading your transcript. Check the correctness of your transcript and attempt to fill in any blanks you left earlier. Transcriptionists often find they can decipher a difficult word after listening to it again at a later time.
If your instructor gives you the password for the transcript keys, be disciplined and do not consult the transcript keys until you have completed the reports to the best of your ability, using all available references. Comparing your transcripts with the transcript keys at the end of the transcription process will enable you to verify the accuracy of your work.
After you have compared your transcript to the transcript key or received a graded transcript back from your instructor, look up all the words you missed. Write them, correctly spelled, in a journal (an electronic journal is ideal for ease of searching) along with their definitions and two or three sentences that illustrate the correct use of the term. Include the sentence from the report as well.
In addition, analyze the reason for your error. Was it simply inadequate research or did you do a lot of research but fail to find the term? Was your misspelling due to not hearing the word clearly or failure to apply rules of phonics? Did you use a soundalike and fail to verify the definition? There are many more questions you can ask yourself about why you misspelled a word, transcribed the wrong term, or left a blank. Once you determine why you made the mistake, you should develop a strategy for avoiding that kind of mistake in the future. If you need help in analyzing your errors or developing avoidance strategies, talk with your instructor.