Transcription help
READING ASSIGNMENT
Your project must be submitted as a Word document (.docx, .doc)*. Your project will be individually graded by your instructor and therefore will take up to a few weeks to grade.
Be sure that each of your files contains the following information:
· Your name
· Your student ID number
· The exam number
· Your email address
To submit your graded project, follow these steps:
· Log in to your student portal.
· Click on Take Exam next to the lesson you’re working on.
· Find the exam number for your project at the top of the Project Upload page.
· Follow the instructions provided to complete your exam.
Be sure to keep a backup copy of any files you submit to the school!
Instructions
You’re required to complete and submit the assignments below.
To access the recorded dictations used to complete this graded project, click here.
1. Transcription Assignment 1: Chart Notes 13, 14, 15 Access the recorded dictation as provided and prepare the chart notes. Be sure to transcribe the letter as dictated.
2. Transcription Assignment 2: Report 32 Access the recorded dictation as provided and prepare the H&P. Be sure to transcribe the letter as dictated.
3. Transcription Assignment 3: Report 39 Access the recorded dictation as provided and prepare the discharge summary. Be sure to transcribe the letter as dictated.
4. Editing Assignment 1: Chart Notes 16 and 17 Access the transcribed document and audio file for the chart notes and edit for errors in spelling, punctuation, grammar, and format.
5. Editing Assignment 2: Report 33 Access the transcribed document and audio file for the H&P, and edit for errors in spelling, punctuation, grammar, and format.
6. Editing Assignment 3: Report 41 Access the transcribed document and audio file for the Operative Report, and edit for errors in spelling, punctuation, grammar, and format.
How To Complete the Assignments
1. Type or proofread each item in the order given.
2. Review your work carefully. For the transcription assignments, it’s a good idea to replay the file and listen to it as you read each report. You’ll be able to catch any errors and reinforce your terminology at the same time. Don’t rely on a computer spell checker. For the proofreading and editing assignments, reread the document to find additional errors you may have missed. It may also help to read the document aloud to catch any mistakes.
3. Be sure to include your name, student number, Medical Transcription 2 Graded Project, and examination number (03984600). In addition, include the title of the assignment in the top right corner (Transcription Assignment 1, Editing Assignment 1, and so on).
4. Single-space the bodies of the reports to be submitted.
5. Follow the exact format provided in the dictated recording. Use your initials and the current year for submitted reports.
6. If you can’t understand a word or phrase in the dictation, check your medical dictionary and the terminology section of the corresponding chapter in your textbook. If a word has already been given in the terminology section of a previous chapter, it will be used again without being listed—once you use a word, you’re expected to remember it. You may have to check earlier chapters’ lists to find the word. Also check the lists of medical terms and the lists of drugs, instruments, tests, and other terms in the Appendix.
7. If you’re still unable to transcribe the word, make an educated guess. If you can’t transcribe a word, it’s better to leave a blank space on your dictation and properly flag the missing entry than to guess and use the wrong word. Please refer to your textbook for information on proper flagging.
Submitting Your Work
You must submit these six reports in ONE word-processing document and not as individual files in a folder. If you’ve completed the assignments as individual documents, you’ll need to copy and paste all assignments into ONE word-processing document. Acceptable formats for submitting your work include Microsoft Word documents (.doc and .docx) or Rich Text Format (.rtf). No other format is to be used for submitting this project. Each assignment is individually graded by your instructor and therefore takes up to a few weeks to grade.
Grading Criteria
The following criteria applies to the transcription portion of the project, which demonstrates your ability to transcribe various letters and medical reports from audio files.
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Part 1: Transcribe Completely All transcribed reports/letters must be accurate and complete. Errors: · Missing words or additional words · Missing sentence · Missing paragraphs · Missing letterhead |
Maximum possible points = 4 If the error is demonstrated 1-5 times, 2-point deduction Error demonstrated more than 5 times = 4 points deductions |
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Part 1: Written Communication Free of ID Errors: 1. Complete date, in a traditional format, on all letters, reports, and entries into the medical record and official documents. 2. Include reference initials |
Maximum possible points: 4 If the error is demonstrated: 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Error demonstrated more than 16 times: 4-point deduction |
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Part 1: Accuracy Drug Name/Lab Values 1. Medications can be transcribed in the generic form or the brand-name form of the medication. 2. The proper format for transcribing numerals and decimals. 3. Use of the abbreviation "ml" or "mL" in place of the abbreviation "cc." 4. Format for transcribing numerals with a label. |
Maximum possible points = 4 If the error is demonstrated: 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times = 3-point deduction Error demonstrated more than 16 times = 4-point deduction |
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Part 1: Accurate Abbreviations 1. Specific parts of the medical reports where abbreviations are not allowed. 2. Use of the abbreviation used for suture materials
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Maximum possible points = 4 If the error is demonstrated: 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Error demonstrated more than 16 times: 4 points deduction |
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Part 1: Correct Use of Numerals 1. Transcribe numbers in medical reports as numerals. 2. Use of roman numerals |
Maximum possible points = 4 If the error is demonstrated: 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Error demonstrated more than 16 times = 4-point deduction |
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Part 1: Flag Not recommended in your graded project. Use correct procedure. |
Maximum possible points: 4 If the error is demonstrated: 1-5 times = 1-point deduction 6-10 times = 2-point deduction 11-15 times = 3-point deduction Error demonstrated more than 16 times = 4-point deduction |
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Part 1: Misspelled Medical Terms/Words 1. Care in proofreading the report for misspelled words. 2. Word "follow up" is common in medical dictation. 3. Correct use of eponyms |
Maximum possible points: = 4 If the error is demonstrated: 1-5 times = 1-point deduction 6-10 times = 2-point deduction 11-15 times = 3-point deduction Error demonstrated more than 16 times = 4-point deduction |
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Part 1: Accuracy Verb Tenses Take care in selecting the verb tense used in letters and medical reports |
Maximum possible points = 4 If the error is demonstrated 1-5 times = 1-point deduction 6-10 times = 2-point deduction 11-15 times = 3-point deduction Error demonstrated more than 16 times = 4-point deduction
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Part 1: Correct Use of Punctuation 1. Uses for the comma 2. Uses for the hyphen. |
Maximum possible points = 4 If the error is demonstrated 1-5 times = 1-point deduction 6-10 times = 2-point deduction 11-15 times = 3-point deduction Error demonstrated more than 16 times = 4-point deduction |
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Part 2: Format 1. Three formats for transcribing letters, the parts of the letter, and the spacing of the parts of the letter on the page. 2. Reference line in the location |
Maximum possible points = 2 If the error is demonstrated 1-5 times: 1-point deduction Error demonstrated more than 5 times = 2-point deduction |
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Part 2: Format Correct information in the second page heading. |
Max possible points = 2 If the error is demonstrated 1-5 times = 1-point deduction Error demonstrated more than 5 times = 2-point deduction |
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Part 2: Format Follow the dictated information as presented on the audio file |
Maximum possible points = 2 If the error is demonstrated 1-5 times = 1-point deduction Error demonstrated more than 5 times = 2-point deduction |
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Part 2: Format Paragraphing in medical reports can be difficult. |
Maximum possible points = 2 If the error is demonstrated 1-5 times = 1-point deduction Error demonstrated more than 5 times = 2-point deduction |
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Part 2: Format The signature block includes the typed signature line of the author of the letter, note or report, the initials of the dictator and transcriptionist, and the date of dictation and the date of transcription. |
Maximum possible points = 2 If the error is demonstrated 1-5 times, 1-point deduction Error demonstrated more than 5 times = 2-point deduction |
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Part 3: Miscellaneous Additional errors recorded by grader. |
Maximum possible points = 10 |
Editing
Please read the instructions in the study guide and copy and paste the entire report for the editing assignment.
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Part 1: Written Communication Clarity and complete thought: Listen to the audio file and read the provided report before attempting to begin the editing process. |
Maximum possible points = 4 If the student has correctly completed the assignment, no point deduction. |
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Part 1: Accuracy Drug Name/Lab Values 1. Medications can be transcribed in the generic form or the brand-name form of the medication 2. The proper format for transcribing numerals and decimals 3. Use of the abbreviation "ml" or "mL" in place of the abbreviation "cc." |
Maximum possible points = 4 If the error is demonstrated 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Error demonstrated more than 16 times = 4-point deduction |
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Part 1: Accuracy Abbreviations 1. Specific parts of the medical reports where abbreviations are not allowed. 2. Use of the abbreviation used for suture materials. 3. Use numerals when numbers are used directly with symbols, words, or abbreviations. |
Maximum possible points: 4 If the error is demonstrated: 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Error demonstrated more than 16 times = 4-point deduction |
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Part 1: Accuracy Numerals 1. Transcribe numbers in medical reports as numerals. 2. Use of Roman numerals. 3. Format for transcribing numerals with a label |
Maximum possible points = 4 If the error is demonstrated 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction |
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Part 1: Accuracy Verb Tenses Take care in selecting the verb tense used in letters and medical reports |
Maximum possible points: 4 If the error is demonstrated 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Error demonstrated more than 16 times = 4-point deduction |
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Part 1: Misspelled Medical Terms/Words 1. Care in proofreading the report for misspelled words 2. Word "follow up" is common in medical dictation
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Maximum possible points = 4 If the error is demonstrated 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Error demonstrated more than 16 times = 4-point deduction |
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Part 1: Correct Use of Punctuation 1. Uses for the comma 2. Uses for the hyphen |
Maximum possible points = 4 If the error is demonstrated 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction |
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Part 1: Correct Signature Block Typed signature line of the author of the letter, note, or report; the initials of the dictator and transcriptionist, and the date of dictation and the date of transcription |
Maximum possible points = 4 If the error is demonstrated, 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Error demonstrated more than 16 times: 4-point deduction |
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Part 1: Correct Use of Capital Letters Use of capital letters in medical transcription |
Maximum possible points = 4 If the error is demonstrated 1-5 times: 1-point deduction 6-10 times: 2-point deduction 11-15 times: 3-point deduction Error demonstrated more than 16 times = 4-point deduction |
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Part 2: Format Format is not graded in the editing portion of the graded project because the format is presented to the student in the report provided. |
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Part 3: Miscellaneous Additional errors noted by the grader |
Maximum possible points = 4 Total points = 40 |