Quiz - Week 43
Proofreading/Editing Quiz
Because the laboratory data is so fraught with potential for error, here’s another proofreading/editing quiz with different tests than the previous one. As before, it is a compilation of actual mistakes made by working transcriptionists (some of them newbies). It does not represent studies done on a single patient or mistakes made by a single transcriptionist. However, it does show typical mistakes that many MTs make.
Instructions: Identify and correct the mistakes in the following paragraph. There are 12 errors that involve wrong words, slang usage, incorrect abbreviations, and errors in numbers. There are no punctuation or grammatical errors, but there are some errors that might be considered style errors. An explanation of the errors is included with the answer key online.
LABORATORY DATA
Urinalysis, per nurse's report, was very concentrated. Urine analysis revealed urine yellow and hazy, specific gravity 1,023, positive leukocyte esterase +3, negative nitrates, p8 of 5, trace protein, glucose negative, trace ketones, urobilinogen normal, bilirubin negative, 3+ blood, 10-15 RBCs, 30-50 WBCs, 1+ squamous cells, plus bacteria. CNS screen was positive for P aeruginosa sensitive to most antibiotics tested. Lumbar puncture showed white blood cell count 178,000, red blood cell count of 7,000,000. The patient's December 1, 1998, chest CT scan (I have reviewed the films) shows a moderate left peripheral edema. BMP 80 pg/mL.
Study Tip - Week 43
Readin’, Writin’ and ‘Rithmetic
Okay, let’s forget arithmetic. Except for being familiar with how to render fractions in English and metric measurements and the abbreviations for metric units of measure, medical transcription doesn’t involve much arithmetic. Even calculating production is often done in the background. So, let’s talk about the other two.
Do you know that being a good reader and a good writer can greatly improve your skills as a medical transcriptionist? Reading widely broadens your horizons, makes you more culturally and geographically literate, increases your English and medical vocabulary, gives you vicarious experiences to which you can relate your academic learning, and generally makes life more interesting. It also makes you more interesting to others!
Very few MTs admit to not liking to read. Many love word puzzles, Scrabble, etc., in addition to being voracious readers. More than a few admit to enjoying reading the dictionary! Many students feel so bogged down in reading for their classes, they admit to abandoning reading for pleasure. While understandable, that’s not good. At a minimum, you should find time to read medical and science news online or in the newspaper. If you use Google or Yahoo as a home page, you can choose to have a variety of medical news sites on your home page. AHDI journals and e-Perspectives have at least one medical article in each issue. Better still, try to read at least one non-class-related book a month. An Amazon.com book search for medical fiction yielded over 6000 results; you’d be surprised how much you can learn (and catch a few mistakes!) in fiction books. You should also read books and articles for the lay public by medical and science writers like Lewis Thomas. Finally, read well-written books from a broad range of genres and authors.
Reading well-written books also improves your grammar, punctuation, and English language skills, thus making you more competent in punctuating and editing problem dictations. Reading widely will also help you become a better writer. More on writing in next week’s tip.
Interpreting Radiology & Imaging Dictation!
The SUM Program Career Development Series products are designed primarily for working transcriptionists who need to improve skills in specific areas, but teachers and advanced students will also appreciate them. Each unit in the series includes 2-3 hours of dictation that is considered "advanced" or "difficult," and also includes ancillary materials to enhance the learning experience.
Interpreting Radiology & Imaging Dictation contains 2 1/2 hours of real dictation with accurate transcripts and ancillary material designed to help transcriptionists improve their skills in this specific area.
The unit includes:
2 1/2 hours of real dictation
119 radiology and imaging reports:
plain
contrast
ultrasound
CT
MRI
nuclear
Accurate transcripts of each dictation
Articles on imaging:
Medical Imaging Procedures
Exercises on Medical Imaging Procedures
Guidelines for Interpreting Radiology and Imaging Dictation
Radiology Quick Quiz
Cross Search: Radiology Imaging
Radiology/Imaging Words and Phrases (750-page e-book)
42 AHDI prior-approved CECs
17 Clinical Medicine
25 MT Tools
Just transcribe the material and check your work against the accurate transcription provided.
The accompanying ancillary material provides guidelines, tips, and exercises to increase your understanding of medical imaging procedures. AHDI offers CEC credit to those who complete the exercises.
Bonus: an electronic version of the entire 750-page reference Radiology/Imaging Words and Phrases.
In medical transcription, time is money, so you can't afford to pass up this opportunity to improve your skills and increase your production on pathology transcription.
Just $99! Download the Table of Contents, then order Interpreting Radiology & Imaging Dictation today!
Answers to Quiz - Week 43
Matching numbered explanatory notes follow the paragraph. When you analyze your errors in your own work, you should perform a similar error analysis and identify ways in which you can avoid similar errors in the future.
LABORATORY DATA
(1) Urine, per nurse's report, was very concentrated. (2) Urinalysis revealed urine yellow and hazy, specific gravity (3) 1.023 positive leukocyte esterase +3, negative (4) nitrites, (5) pH of 5, trace protein, glucose negative, trace ketones, urobilinogen normal, bilirubin negative, 3+ blood, 10-15 RBCs, 30-50 WBCs, 1+ squamous cells, (6) _ + bacteria. (7) C&S screen was positive for (8) Pseudomonas aeruginosa sensitive to most antibiotics tested. Lumbar puncture showed white blood cell (9) count 178, red blood cell (10) count of 7. The patient's December 1, 1998, chest CT scan (I have reviewed the films) shows a moderate left (11) pleural effusion. (12) BNP 80 pg/mL.
1. Urine. The dictator may have said urinalysis or the MT may have made an inappropriate edit. Either way, it’s urine that looks concentrated. Urinalysis is a test.
2. Urinalysis. Although some dictators may say “urine analysis” and you may see it on occasion, the single word urinalysis is the more modern and prevalent term.
3. 1.023. Specific gravity is often dictated like this “one oh two three” or "ten twenty-three" omitting the “point,” but it is always four digits beginning with 1 followed by a point. The MT apparently did not know this and assumed the number was one thousand and twenty-three.
4. nitrites. Possibly the dictator misspoke or the MT misheard, but context is the key to getting this term right. Nitrate (NO3) and nitrite (NO2) are both nitric acid radicals. Certain pharmaceutical compounds like nitroglycerin (glyceryl trinitrate) are referred to generically as nitrates. Nitrate is also present in nature and always present in human urine. Certain bacteria that cause urinary tract infections produce an enzyme (nitrate reductase) that converts the nitrate radical in urine to nitrite, so this test, though not highly sensitive or specific, is a means of confirming a bacterial urinary tract infection.
5. pH. The MT misheard H as 8. In writing this may seem illogical, but say “pH” aloud a few times, and you may hear how it can happen. The mistake is inexcusable, however, because the MT should have confirmed the test in a reliable reference. The pH can be performed on the blood or the urine. It is a measure of acidity or alkalinity; 7 is neutral, below 7 acidic, above 7 alkaline. Although the pH may vary somewhat during the day, a range of 6.5 to 8 is considered “normal.”
6. Although it cannot be determined for certain without listening to the dictation, which is no longer available, a number was probably dictated before the “plus” but was omitted by the MT. The clue here is the “3+ blood” and the “1+ squamous cells.” It is unlikely the dictator would simply say “plus bacteria” without giving a number.
7. C&S was dictated. Here the MT misheard “and” as N. Since what follows are obvious results of a culture and sensitivity study, however, the MT should have realized the mistake immediately. Note: HL7 standards which apply to the electronic health record prohibit the use of all symbols such as the ampersand, degree symbol, etc., you will want to verify with your employer whether C&S is permitted on the job.
8. Pseudomonas. The genus should be spelled out on first use, even in laboratory data.
9-10. WBCs 178, RBCs 7 was dictated. The MT confused a study of the cerebrospinal fluid from a lumbar puncture with a CBC where the white blood count and red blood count are sometimes reported as small numbers (with the exponents understood). Rather than transcribe the exponents, the numbers are multiplied into thousands and millions respectively. Studies on the CSF and urine, however, report the actual numbers of white and red blood cells. An increase in white blood cells is an indication of infection. Red blood cells in the CSF most likely represent a bloody “tap” (lumbar puncture); in the urine RBCs may indicate a kidney stone or other urinary tract condition.
11. PE was dictated. This is most likely an abbreviation expander (software) short form error. When abbreviations can be expanded a number of ways, it is important for the MT to choose short forms that are distinctive, like plef for PLeural EFfusion, puem for PUlmonary EMbolus, and pped for PeriPheral EDema.
12. BNP was dictated. The MT mistook N for M and failed to verify the test in a reliable reference. BNP stands for B-type (or brain) natriuretic peptide, a single test with a single value useful in diagnosing congestive heart failure. BMP stands for basic metabolic panel (or profile), a group of blood chemistry studies that would include results for sodium, potassium, chloride, etc.