Maricopa Community Colleges  MTR202   19916-19942 
Official Course Description: MCCCD Approval: 04/23/91
MTR202 19916-19942 LAB 2 Credit(s) 6 Period(s)
Medical-Surgical Transcription
Transcription of inpatient medical and surgical documents suitable for permanent records of patient care. Transcriptionists proofreading and editing dictation. Application of medico-legal principles of inpatient and outpatient clinical settings. Prerequisites: Admission to program or MTR101 or permission of department. Corequisites: (HUC105, MTR201, MTR203, MTR270, and MTR272.)
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MCCCD Official Course Competencies:
 
MTR202   19916-19942 Medical-Surgical Transcription
1. Transcribe inpatient medical dictation from various originators who may exhibit accents and dialects, with increasing speed and accuracy. (I)
2. Transcribe inpatient and outpatient clinical surgical reports from various originators who may exhibit accents and dialects, with increasing speed and accuracy. (II)
3. Recognize discrepancies in dictation and clarify/edit according to standard transcription procedures. (III)
4. Demonstrate increasing skill in transcriptionist proofreading. (IV)
5. Apply medico-legal principles related to inpatient settings. (V)
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MCCCD Official Course Outline:
 
MTR202   19916-19942 Medical-Surgical Transcription
    I. Medical Transcribing
        A. Documents
          1. history and physical
          2. progress notes
          3. consultation
          4. discharge summary
          5. problem list
          6. other
        B. Medical specialties (originators)
          1. family practice
          2. dermatology
          3. otorhinolaryngology
          4. orthopedic
          5. cardiology
          6. hematology
          7. gastroenterology
          8. obstetrics
          9. gynecology
          10. urology
          11. internal medicine
          12. endocrinology
          13. neurology
          14. neonatology
          15. psychiatry
          16. pediatrics
          17. dentistry
          18. oncology/hematology
          19. ophthalmology
          20. other
        C. Speech variations
          1. accents
          2. dialects
          3. impediments
          4. other
      II. Surgical Transcribing
          A. Reports
            1. format
            2. Joint Commission on Accreditation of Health Care Organizations (JCAHCO) standards
          B. Surgical specialties
            1. orthopedic
            2. plastic
            3. cardiovascular
            4. emergency room
            5. trauma services
            6. general
            7. neurosurgery
            8. dentistry/oral
            9. urological
            10. thoracic
          C. Speech variations
            1. accents
            2. dialects
            3. impediments
            4. other
        III. Recognizing Discrepancies
            A. Common discrepancies
            B. Applying medical terminology/anatomy/physiology
            C. Maintaining meaning
            D. Maintaining style
            E. Listening in context
            F. Inconsistencies
            G. Misunderstandings
            H. "Flagging" procedure
            I. Other
          IV. Proofreading
              A. Transcriptionist method
              B. Techniques
            V. Medico-Legal
                A. Informed consent
                B. Release of records
                C. Patient's rights
                D. Confidentiality
                E. Release of information
                F. Risk management
                G. Research
                H. Post mortem
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