This innovative text uses a simulation approach to give readers interested in healthcare documentation and medical transcription careers a working knowledge of medical reports common in both acute and chronic care settings. Readers have access to transcription of 107 patient medical reports, including 56 new reports exclusive to the Eighth Edition. This edition also features 20 new speech recognition technology/medical editing (SRT) reports, as well as information on electronic health records (EHRs), quality assurance (QA), and scribes to keep readers up-to-date on the latest advances in the field. Organized by body system, the text includes full-color anatomy and physiology illustrations to make medical terminology easier to master. In addition, the authors have included a review of proper formatting, grammar, and style in accordance with the AHDI's BOOK OF STYLE, and a master glossary list compiles key terms in one section for convenient study and quick reference.
Preface.
New to this Edition—Featured Items.
Prerequisites.
Course Description.
Teaching Environment.
Objectives.
Student Text-Workbook.
Audio Transcription Exercises.
Supplements.
Acknowledgments.
About the Author.
Supplements at a Glance.
1. Introduction.
2. Model Report Forms.
3. References.
4. Case Studies.
Case Study 1: Reproductive System.
Case Study 2: Gastrointestinal System.
Case Study 3: Cardiopulmonary System.
Case Study 4: Pediatric Orthopedics/Neurology Systems.
Case Study 5: Psychology/Neurology System.
Case Study 6: Reproductive System/Mammary Glands.
Case Study 7: Orthopedics/Endocrine Systems.
Case Study 8: Vascular/Renal Systems.
Case Study 9: Orthopedics.
Case Study 10: Respiratory System.
5. Quali-Care Clinic.
6. Speech Recognition Editing.
Appendix.
Proofreader’s Marks.
Challenging Medical Words/Phrases/Prefixes.
Sample Patient History Form.
The Lund-Browder Chart.
Laboratory Test Information.
Sample Forms for Ordering Laboratory Tests, Scheduling Radiology Tests, and Consults for Physical Therapy, Sleep Studies, etc.
Building a Reference Library.
Official “Do Not Use” List from The Joint Commission.
Bibliography.
Index.
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Patricia Ireland
Patricia A. Ireland, CMT, AHDI-F, has been active in the field of medical transcription since 1968, both as a multispecialty practitioner and as an instructor. A certified medical transcriptionist since 1981, Ms. Ireland lives in San Antonio, Texas, where she works as a freelance medical/technical author and editor. She has been a medical transcription instructor since the 1970s, has taught online medical transcription programs since 2000, and has co-authored four medical transcription textbooks for Cengage Learning. Ms. Ireland encourages questions and comments about this text and can be reached at pat.ireland68@yahoo.com. Ms. Ireland is an active member of the Association for Healthcare Documentation Integrity (AHDI), as well as the Capital Chapter of AHDI in Austin, Texas.
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Carrie Stein
Carrie Stein, CMT, had over 32 years of experience as an acute-care multispecialty medical transcriptionist when she passed away in late 2015. Her long career included positions with the University of Texas Medical Branch in Galveston, Texas, and the Methodist Healthcare System in San Antonio, Texas. She began teaching online medical transcription courses in 2003, serving as an instructor for Gatlin Education and ed2go. In addition to this title, Carrie was the co-author of THE DICTATED WORD.
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The authors have completely updated and enhanced content for the Eighth Edition, adding 56 new reports reflecting up-to-date medical procedures to help readers enter the profession with accurate knowledge of current industry practices.
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Highlights include two new acute care case studies, all-new chronic care quali-care reports, and a new section with 20 reports covering speech recognition technology/medical editing.
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All acute care case studies now include critical thinking exercises to help stimulate discussion and help readers better understand and engage with the material.
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New information added to the Eighth Edition includes telephone notes (quali-care report 25a, b, c, d), as well as a pulmonary function tests/arterial blood gases document added to acute care case study 3.
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Audio dictation information is provided for all 107 reports—including accents, speed, background noise, difficulty level, and length of file—making it easy to customize a syllabus for any level of beginning student.
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Based on the AHDI BOOK OF STYLE, a new review of formatting, grammar, and style prepares readers to create documents aligned to current industry standards. In addition, a master glossary list now compiles key terms in one comprehensive section, providing a useful, convenient resource for classroom preparation, student review, and professional reference.
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Coverage spans a wide range of key reports commonly used in acute and chronic care settings, including history and physical examinations; consults; operative, pathology, and radiology reports; SOAP and HPIP notes; death and discharge summaries; correspondence; and telephone notes.
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An innovative simulation approach helps immerse readers in the material and provide a practical, working knowledge of common acute and chronic care medical reports to prepare readers for career success in the field of healthcare documentation and medical transcription.
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A flexible structure and wide range of material make it easy to customize courses, lesson plans, and exams. Instruction can begin at any point in the text—focusing on acute care, chronic care, or a mix of reports—and audio dictation information allows for ready customization based on varying levels of student need.
Instructor's Companion Web Site for Ireland/Stein’s Hillcrest Medical Center: Healthcare Documentation and Medical Transcription, 8th Edition
9781305583931