MEDICAL TRANSCRIPTION SAMPLE REPORTS: Screening Colonoscopy

Medical Transcription

Medical transcription is one of the fastest-growing profession in the country today.

Medical transcription offers excellent opportunity to housewives, ex-servicemen, graduate fresh or experienced, especially the newly passed ones. It is also a high income career for the graduates. You can even sit at your home and earn money from home feasibly through medical transcription career, and one can organize his/her own work timings and avoid travel to the works for and thus earn more than the usual office goers.

Nature of job, doctors will dictates the patients’ information, which we will receive in wave format through voice mail or dictaphone which consists of medical datas, which we have to type.

Transcription process is conversion of voice to electronic text form. As this process deals medical data documentation, so this is called medical transcription. The person who deals with medical data process is called Medical Transcriptionist.

Any person can do home based medical transcription program, those who are interested to learn, who able to grasp accents’ of dictators’ voice, who able to understand English, who able to form sentences grammatically and finally, who wants to earn money shortly from home or office.

There are many institutions that providing free home based medical transcription training through internet with their own “terms and condition” and time limits, duration. To avail home based medical transcription training you should computer laptop or desktop with UPS, phone and internet connection for communications. They would design the program accordingly where one can learn medical transcription from home.

Home based Medical transcription Training program duration may be 2 to 4 months.

After successful completion of home medical transcription training from institute based on your quality and quantity, you will be offered a home based job medical transcription immediately, and you are supposed to sign an agreement and can start medical transcription job from home and can start earning from home. Companies will provide you files through internet which has to be transcribed.

Based on your quality and quantity, remuneration will be fixed with incentives per month and remuneration will be gradually increased as your experience increases. One can start earn initially low, but gradually can increase with incentives as experience increases.

Quality - the document should be without error and should not commit error beyond the limit. Files should be submitted with minimum 90% accuracy to company by the medical transcriptionist and to the client, 99.5% accuracy after QC/QA. Quantity - a transcriptionist should be able to transcribe minimum of 350 lines per day, initially after successful training.

Main advantage of taking home based medical transcription work, one can organize their own work timings. They can reduce your traveling time 2 to 4 hours, so that can spend more time in working to earn more.

Thursday 2 August 2012

Screening Colonoscopy

PROCEDURE: Colonoscopy.

INDICATION: Screening

PROCEDURE IN DETAIL: Indications, risks, benefits, alternatives, and limitations were explained to the patient in the office. Risk of anesthesia, perforation, bleeding, infection, colitis, cardiopulmonary risk, morbidity, and mortality were discussed. Possibility of missing a lesion, a polyp, a growth, a mass, and cancer was discussed. Risk of cold biopsy, hot biopsy, and polypectomy was discussed. Risk of the prep was discussed. All these discussions were done in the office. She understood all of the above. All her questions were answered. She agreed to the procedure. She came to the endoscopy unit today. She had no further questions or concerns. She said she is prepped well. Physical exam was grossly negative. She was given informed consent. She was then taken to the endoscopy room. Anesthesia provided sedation. Scope was advanced into the rectum all the way to the cecum. Tortuous colon application of pressure was required to get to the cecum. Cecum was identified by the ileocecal valve and appendix. Photographs were taken for documentation. Small bowel could not be intubated. Mucosa was then examined on withdrawal. There was some liquid and pasty stool throughout the colon, as much as possible was cleaned out. Small lesions or flat lesions could have been missed. The cecum, the ascending colon, transverse colon, descending colon, sigmoid colon, and rectum were carefully examined. Retroflexion was done in the rectum. Over 6 minutes was taken to evaluate the colon on withdrawal. Findings were that of grossly negative colonoscopy. Small-to-moderate internal hemorrhoids. Procedure was completed. The patient tolerated the procedure well.

IMPRESSION: Screening colonoscopy grossly negative, small-to-moderate internal hemorrhoids.

PLAN: Fiber supplement. Hemorrhoid suppositories. She can buy OTC. The patient to do annual Hemoccult screening with primary care doctor. Colonoscopy in 5 to 10 years, unless otherwise indicated. Follow up in my office. Follow up with PCP

MEDICAL TRANSCRIPTION SAMPLE REPORTS

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