This practical text provides an understanding of how medical documents work and how to create them accurately. Emphasizing medical and English grammar, it explains fundamental concepts on every aspect of medical transcription – including the various formats used in transcribing letters, chart notes, emergency room notes, history and physical exams, and operative and specialty reports. This fifth edition provides a wealth of exercises that reinforce the material in the text, as well as a complete review of grammar, punctuation, capitalization, symbol use, reference research, plural forms, the various equipment used in medical transcription, and the legal aspects of medical records. Content on grammar skills demonstrates the correct use of punctuation, capitalization, numbers, abbreviations and symbols, word endings, formation of plural forms, and more – with numerous practice exercises to provide the fundamental knowledge necessary to work in the field. Authentic medical transcription documents illustrate how to set up special formats for medical office charts, history and physical exams, operative reports, x-ray reports, and pathology reports. Exercises and helpful hints allow readers to practice their proofreading and editing skills. Skill drills using the medical dictionary, drug references, and laboratory values demonstrate how to find and use references. A chapter on Equipment explains how to operate the equipment used in the workplace and how to make informed decisions when purchasing equipment for personal use.
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