JUMP START PROGRAM INFORMATION
If you have been placed in the Jump Start Internship Program, Congratulations! Below is additional information regarding what you will need to have available before you begin as well as some tools and resources to help you prepare and succeed during the internship. If you have not yet applied for the internship program, please do so here.
Before you begin your internship, there are two reference items we recommend that you purchase if you do not already have access to them as they are necessary to be successful.
These are all available through Amazon.com, AHDIonline.org, or Stedmans.com:
1. AHDI Book of Style (current edition)
Note: Alternatively, you can purchase a subscription to the KB Benchmark website (available through AHDI). If you were provided a subscription to this site as part of your enrollment, you may want to continue the subscription in lieu of purchasing the Book of Style.
2. You will also need to purchase a quality Medical Spell Checker for your computer. We do recommend you purchase this from Stedman’s as it is one of the best in the industry.
There are also other reference items you may wish to purchase as you are able. They include:
1. Medical word dictionary. One of the best is provided through Stedman’s and is on CD.
2. Word books for specialties you consistently transcribe. Stedman’s has a large library of these books available. You can purchase them through Stedman’s directly or other book sellers, including Amazon. (They offer discounts sometimes for buying more than 1 so be sure and ask or check the website)
3. The Quick Look Drug Book by Stedman’s on CD.
4. Stedman’s Medical Terms and Phrases – this is a hard-copy book.
5. Any book of normal lab values. (Make sure you get one published recently, however.)
Also, a valuable tool to have, during and after your internship, is a good word expander program. This is a productivity tool to help you increase your line counts as you transcribe. You can see Jon Knowles’ website at jonknowles.net for an overview of expanders, and to learn how to use the “ABCZ” system for creating abbreviations for your word expander. Jon also sells word lists that can be imported into either the word expander Shorthand or Instant Text. We recommend either Shorthand or Instant Text. Instant Text (IT) is the most comprehensive and can do the most, but it does have a learning curve. With IT, you can scan your medical reports and it will cull out the most typed words and can be set to automatically create ABCZized abbreviations for those words.
For some extra pointers on being an MT, here are some links:
Ergonomic Tips for Medical Transcriptionists
Specifics You Must Know For Your Internship
Most important to note from the beginning, internship means that you have completed your studies in medical transcription and that you have a graduated with a certain level of expertise. It should be noted by anyone entering the MT field, whether interning or starting a job in the profession, that the importance of accuracy and paying attention to reports you transcribe cannot be overstated. Reference the article HERE on what can happen to services and MTs who make critical patient safety errors and their liability. We should all realize that critical patient safety errors can potentially (and do) result in patient deaths. We are held accountable and can be prosecuted in a court of law if errors we make in transcription result in a patient being harmed or by way of worst case scenario, dying.
What constitutes critical patient safety errors? Read the list that is downloadable mentioned below for a list of the errors. In brief, critical safety errors usually involve misrepresentation of what a patient has or does not have or assigns wrong medication or dosages to that patient. For instance, it is dictated the patient does have HIV but the MT or intern types the patient does not have HIV. The report came back positive for leukemia but it is stated that the report did not come back positive for leukemia. Wrong medications, wrong medication dosages, such as in the article mentioned above, wrong laboratory values, omission of critical information—these are the kinds of errors we all want to avoid because they can have grave consequences for a patient.
Remember to stay engaged for the entire report when you are transcribing. Think about the whole report, flag discrepancies, and ask questions and/or leave blanks if you are uncertain of anything. Go back and get confirmation of blanks to enhance your knowledge but above all, do not put anything into a report ever that could cause harm to a patient if you are unsure. If in doubt, leave it out—leave a blank and have someone explain to you what was supposed to be transcribed there.
Specifics about the internship and what you need to know:
- Lots of the internship reports you will be doing will be autopsy reports. This is an extremely technical specialty of medicine that has a lot of material based upon anatomy and physiology. Please see instructor websites and download all materials under Autopsy (click HERE) and Autopsy Presentation (click HERE). Ask questions about anything you are unsure of.
- The autopsy reports will contain difficult terminology. Interns must be aware of how to decipher terminology but more importantly how to look up medical terminology. Please see this website page for lots of PDF files (download, read and keep in a binder) as well as a great video presentation on medical terminology. Click HERE.
- Reliable websites should be used to verify medical terminology, drugs (whether generic or brand name), grammar, instruments, etc. In other words, if you are not 100% sure of the spelling, the definition, or whether a drug is generic or brand name—look it up! For some recommended websites, click HERE. There are also downloadable PDF files for future reference.
- Cranial nerves are requested to be noted as Roman numerals NOT Arabic (cranial nerves II-XII).
- Use the Internet to look up proper spelling of MD names or places. If a certain town is mentioned, use the Internet to look up an MD in that town. The same goes for looking up names of cities. Yahoo or Google can provide city listings–for example cities in Washington starting with the letter “W.” You then drill down the list until you find the appropriate spelling. Use US50.com to find the state you want to search in, then click on the city link for a list of cities in alphabetical order.
- NEVER trust the spelling that the dictator gives for difficult words, drugs, operations, places, etc- always look up to confirm spellings.
- Contractions should NEVER be used in medical reports unless it is a direct quote. (Examples: Don’t, I’m, we’ll, they’re, it’s, etc). Exception: Quote such as “I’m sick.” (In this case, the patient stated this so it is acceptable—other situations—never use contractions.) For more help with contractions, click HERE. (See quiz 18)
- Review the JCAHO list of dangerous abbreviations – download if you do not have, print out and place in a binder for reference. It must be adhered to in its entirety. For a copy, click HERE and download.
- Formatting should always be consistent throughout every report. The rule of thumb is to inquire as to how dates should be formatted (for instance May 24, 2013 or 05/24/2013 or 5/24/13). Once you have confirmed what the formatting preference is, it must be followed consistently. If you do not have a list of detailed account specifics (what the client has determined should be the formatting choice for dates and other items), request one. Print it out and keep in a binder. Refer to it every time you need to reaffirm formatting choices.
- Review the word it’s versus its. The word it’s is a contraction meaning it is. This is the only meaning of this word! For help with contractions, click HERE. See quiz 18 specifically.
- Review ESL dictators and techniques required. Remember that grammar should be corrected when typing for a foreign MD. For instance, subject/verb disagreement should be fixed and not left “as dictated.” For more information on techniques needed when doing ESL dictators, click HERE.
- Do not capitalize the words emergency room in this situation ever—unless it is preceded by a proper name. Example: The patient was sent to the emergency room. But: The patient was sent to the St. Joseph Emergency Room.
- You will be exposed to an incredible amount of lab work!! Some constants would be the CMP, CBC, BMP and BNP (know the difference between BMP and BNP), and what results are included in each test:
- CBC: Hemoglobin, RBC, WBC, hematocrit, MCHC, MCV, platelet count, etc
- CMP: Potassium, sodium, chloride, BUN, creatinine (frequently misspelled by interns), albumin, etc
- RPR, HIV, hepatitis C, B and so on.
- EKG: How to correctly type the leads, T-wave, ST-wave, R-wave, PR intervals, etc. For a list of leads and how they are typed, click HERE. For a more detailed presentation on the EKG and what it shows about the heart, click HERE.
- Urinalysis: Specific gravity (way to note such as 1.020), ketones 3+, protein 2+, blood, etc
- For lab PDF’s, click HERE. Print out, keep in a binder and review until you have memorized correct names for tests and spellings
- Acronyms must be spelled correctly and you must know the correct expansion for them. This means that you should look up each and every one to verify that it is the correct acronym for the context of the transcription. Use Acronym Finder by clicking HERE. Also click HERE and download the file on emergency room acronyms that may be helpful. Some common ones: DTR, ACU, ARS, BMP (usually typed BNP which is a way different test and a critical patient error), H&P vs. HNP, S1 S2 for heart sounds, HEENT, CNS (distinguish from C&S), D&C (not DNC).
- Accuracy is crucial. TAT (turnaround time) is also vital. That being said, typing speed is also a very important component of MT work as most work is based on production. That means simply the slower you type, the less money you stand to make. However, keep in mind that a fast typing speed with lots of errors or multiple blanks will get you fired before a slower typing speed with accurate reports will. For a fun way to work on increasing your typing speed, click HERE. If you want to accurately assess your typing speed and accuracy rate, click HERE. There are many things that help people increase their typing speed but they vary from person to person. Google techniques on how to increase your speed but most importantly, strive for accuracy.
- Errors in MT work are generally assigned a point value. Even without points being assigned, there are levels of errors. It’s important to know what degree of severity is assigned to a certain error and why so always ask your mentor or supervisor about any errors you make. Most importantly, and vital to your success as an MT—you must follow feedback. Not part of it, not parts you think are easier to remember—all of it. This is a common mistake among students and new MTs. Feedback is given to you for a reason and that feedback is your ticket to becoming proficient at your job. For a detailed list of errors in medical transcription and how they are calculated (from minor to major to critical patient safety errors), click HERE to read How the Medical Transcription Theory & Practicum is Graded.
- Medical Transcription is a detail-oriented, precise, no-room-for-error career. It is very rewarding and can be very lucrative. Not all professions have an internship program available so the existence of such a program is a treasure. Use it wisely and consider it an incredible gift you receive along your path to employment. Accept the guidance that you are provided and never stop researching, learning or asking questions.