In addition to learning the unique language used by medical professionals, a medical transcriptionist must also be an expert in grammar and writing English. As if this is not enough to remember, there are styles and formats that are unique to medicine; not familiar with these accepted guidelines, can create quality assurance problems for transcriptionists and medical records and affect patient safety.
Medical homonyms
Homonyms are difficult to master in many Englishmen, but when they occur in a medical language, it becomes even more difficult. For example: ileum and ileum. These are medical terms that refer to two different anatomical areas. To choose the correct spelling, you need to be familiar with anatomy and look at the context in which this word occurs. Experienced transcriptionists develop a mnemonic system that helps them find the correct spelling of a homonym.
A slider is a bone in the pelvic region; in easy terms, hip joint. The ileum is part of the small intestine. Easy mnemonics is to remember that both thighs and ileal have the letter “i”. After this, the transcriptionist needs to look at the context of the use of the word in order to apply the appropriate term and spelling.
Although they are not considered to be homonyms, there are terms that sound like something completely different, which leads to a transcription error, usually by an inexperienced transcriptionist. “Below amputation of the knee” is often mistaken for “ambition balois.” An experienced transcriptionist knows that there is no such thing as “baloi ambition”, regardless of whether it sounds like the dictator says! In medical transcription, they are called "sound" errors.
Abbreviations
Abbreviations are very common in medical terminology. They allow doctors and other health care professionals to quickly document records. Unfortunately, there are many terms that can be applied to one abbreviation, which can lead to errors. The Institute for Safe Drugs (ISMP) has published a list of terms and abbreviations that can be misinterpreted, and said that they must be written or rewritten in a certain way to avoid confusion.
In medical terminology, the abbreviation OD or od can be either the right eye or once a day. It is important that the medical transcriptionist know that the ISMP recommends not using either the abbreviation or its abbreviation, as it is necessary, to write out as “right eye” or “daily.”
Abbreviations may also be misinterpreted, since one letter closely resembles another, even in a typewritten report. The ISMP also recommends using the abbreviation “IU” (International Units), since it can be taken as “IV” (intravenous).
There are also guidelines governing abbreviations for measurements. The use of the abbreviation "cc" (cubic centimeters) is common, but not recommended; documentation professionals are advised to use the abbreviation “mL” (milliliters) instead of “cc” to be misunderstood.
Documenting accuracy and clarity
The main recommendations on the style and format of medical transcriptions are aimed at documenting the recording with accuracy and clarity so that other health professionals can easily find and read the information they need to make health decisions, while feeling confident that the record is accurate, as the transcriptionist is able to interpret the spoken word and intent of the dictator.
