Quiz - Week 35
Proofreading/Editing Quiz
This proofreading/editing quiz is a compilation of actual mistakes made by working transcriptionists (some of them newbies). It does not represent studies done on a single patient or mistakes made by a single transcriptionist. However, it does show typical mistakes that many MTs make.
Instructions: Identify and correct the mistakes in the following paragraph. There are 16 errors that involve wrong wrods, slang usage, incorrect abbreviations, and errors in numbers. There are no punctuation or grammatical errors, but there are some errors that might be considered style errors. An explanation of the errors is included with the answer key online.
LABORATORY DATA
CBC came back normal with Hgb of 15 and crit of 45. Red cell distribution was normal chromic, normal cytic with MCV of 80 femtoliters, an MC8 of 30 picograms, and an MC8C of 35%. WBC showed 30,500 white cells; differential revealed neuts 73, lymphs 24, monos 2, basos 1. RBCs were 4.5 million. Retic count was 0.5. Platelet count is 75,000. Western Green sed rate was W&L. Lytes showed a sodium of 134, K of 4.1, chloride 99, CO2 not done, glucose 134. BUN and creatine are 79 and 4.5 respectively. Protein and albumin are 5.6 and 2.3 respectively with calcium 9.4. Total bili is 32.3. ASD and alk phos are 128 and 164 respectively.
Study Tip - Week 35
Soundalikes are the bane of students and practitioners. There are hundreds, perhaps thousands of medical, not to mention English, words and phrases that sound so like other words and phrases that it’s easy to get lost in La-La Land and type the wrong word. Abbreviations are particularly troublesome because so many consonants are indistinguishable when carelessly pronounced (and sometimes when very carefully pronounced!). Nowhere is this irksome problem more obvious and more disastrous than when transcribing laboratory data. Just as you should never transcribe a term that you do not know the meaning of, you should never transcribe an abbreviation that you cannot translate and know that it fits the context.
Did the dictator say BMP or BNP or B&P? CBC or CVC or See VC? CNS or C&S or CMS? FVC or FBC? MCH or MC8? PCO2 or DCO2? (Note: Some of these examples are NOT legitimate laboratory abbreviations!) Brief forms, acronyms, and slang also abound in laboratory data dictation. While some brief forms, like segs, bands, and lymphs are acceptable, others like alk phos and crit are not. You will need to consult a medical transcription style guide to determine the acceptability of some brief forms. One more word of caution: If you use an abbreviation expander, it’s easy to get an inadvertent expansion due to similar abbreviations.
A good laboratory reference book that groups related laboratory studies together by the group name (CBC, CMP, BMP, electrolytes, etc.) will be invaluable to you as a student and a practitioner. You may want to acquire a pocket laboratory reference such as the ones nurses and residents use for quick reference or find a good website that provides reference ranges, reason for study, and implications of abnormal results. Google “reference ranges common laboratory tests” without the quotation marks and bookmark the site that you like best.
Interpreting Acute Care Dictation #1
An all-new unit in The SUM Program Career Development Series is now shipping. HPI has developed these short, advanced-level units to help transcriptionists broaden their skills in specific areas and to give advanced students more experience. Interpreting Acute Care Dictation #1 focuses on these report types:
The CD includes these features:
- 3 hours of real acute care dictation about real patients (no script-read dictation)
- 49 reports
- Transcript answer keys to compare with your own transcript
- Original articles on editing, research, abbreviations, slang, jargon, managing risks, and QA best practices.
- Guidelines from industry experts for transcribing acute care dictation.
- A quick-reference list of medical phrases used in the dictation.
This unit has been prior-approved by AHDI for 10 CECs
Read a detailed Table of Contents, then order.
Answers to Quiz - Week 35
Matching numbered explanatory notes follow the paragraph. When you analyze your errors in your own work, you should perform a similar error analysis and identify ways in which you can avoid similar errors in the future.
LABORATORY DATA
CBC came back normal with Hgb of 15 and (1) hematocrit of 45. Red cell distribution was (2) normochromic, normocytic with MCV of 80 (3) fL, an (4) MCH of 30 (5) pg, and an (6) MCHC of 35%. WBC showed (7) 13,500 white cells; differential revealed (8) neutrophils 73, lymphs 24, monos 2, basos 1. RBCs were 4.5 million. (9) Reticulocyte count was 0.5. Platelet count is 75,000. (10) Westergren sed rate was (11) within normal limits. (12) Electrolytes showed a sodium of 134, (13) potassium of 4.1, chloride 99, CO2 not done, glucose 134. BUN and (14) creatinine are 79 and 4.5 respectively. Protein and albumin are 5.6 and 2.3 respectively with calcium 9.4. Total (15) bilirubin is 32.3. (16) AST and (17) alkaline phosphatase are 128 and 164 respectively.
ERROR ANALYSIS
1. The slang brief form crit is not acceptable. One of the things that makes a brief form slang is when the brief form is taken from the middle or end of a word. You may want to either abbreviate hematocrit to Hct or expand Hgb for consistency.
2. normochromic, normocytic. Used alone, chromic means pertaining to chromium. Used here, it is a combining form meaning color. This pair of compounds is commonly used to describe red blood cells having normal levels of hemoglobin.
3. fL. Metric units of measure such as femtoliter should always be abbreviated when accompanied by a number.
4. MCH. Note that H can sound like 8 when not enunciated clearly or when there is background noise. MCH stands for mean corpuscular hemoglobin. Abbreviations such as this are not expanded in laboratory data, but it’s important to know what they stand for so that mistakes such as this aren’t made.
5. pg. See #3 above. You may want to get a table of S.I. (metric) units of measure and their abbreviations and keep it handy, especially for units of measure that are less common, like femtoliters and picograms.
6. MCHC. See #4 above. MCHC stands for mean corpuscular hemoglobin concentration.
7. The MT misheard 13,500 (a near-normal white blood count). The clue is the “CBC came back normal…” In addition, there is no mention of a culture to identify an infection. When you have a whole report, you would check other parts of the report for verification.
8. Neutrophils. Neuts would probably be considered slang if it were in common use, but since it is an uncommon brief form for neutrophils and to use it would hinder easy communication, it should be written out in full. (The physician who dictated this was abbreviating everything.)
9. Retic is one of those brief forms that may or may not be considered an error depending on facility standards. If you did not count is as an error, that’s ok.
10. Westergren. "Western Green" appears to be an error made by an MT who either thought she or he heard it clearly and spelled it like it sounded or someone who was simply too lazy to look up the term. The two most common methods for determining the erythrocyte sedimentation rate are the Wintrobe and Westergren, named for the developers. The brief form sed rate for sedimentation rate is widely accepted.
11. WNL was dictated and might be acceptable in some facilities. N and M are common mishears for the word and and vice versa. This is an instance where it’s essential to be sure you know the translation of an abbreviation. Writing out within normal limits is recommended unless instructed otherwise.
12. Electrolytes. As noted in your tip for this week, lytes (not lights) is an unacceptable slang form because it is taken from the end of the term.
13. K is the abbreviation for potassium and was dictated. The dictator was possibly reading from handwritten notes where such notations are common, but it’s inappropriate to use in a transcribed report that is intended to be a record of a patient’s medical care in perpetuity.
14. creatinine. It’s possible that creatine was a misspeak by the dictator or that the MT doesn’t know the difference between creatine, an amino acid found in the muscle, and creatinine, a breakdown product of phosphocreatine excreted in the urine. Creatinine and creatinine clearance tests are always done on the urine. In laboratory blood studies, you might hear creatine kinase (CK) or creatine phosphokinase (CPK), the former name for creatine kinase when myocardial infarction (MI) is suspected. There are three distinct isoenzymes: CK-MB, CK-MM, and CK-BB. CK-MB (found primarily in the heart) in particular and to a lesser extent CK-MM (found in muscle) may be elevated in MI, but may also be elevated after intense exercise. CK-BB is found in the brain and is rarely included in laboratory data.
15. Bilirubin. Bili was dictated but is considered slang.
16. AST stands for aspartate transaminase and is a liver enzyme. It is one of those abbreviations that communicates better if it is not expanded. However, the MT apparently heard the “t” as a “d” and failed to verify it in a laboratory reference.
17. alkaline phosphatase. Again, as noted in your tip for this week, alk phos, although dictated, is considered slang and should be expanded.
Note: Yes, there are 17 explanations and you were told there were only 16 errors. Retic (#9) was not counted among the errors because it is widely acceptable.