HISTORY AND PHYSICAL EXAMINATION OR EMERGENCY DEPARTMENT TREATMENT RECORD Patient Name: Brenda C. Seggerman Patient ID: 903321 Date of Admission/Data of Arrival: 03/27/2013 Admitting/Attending Physician: Alex Mcclure‚ MD Admitting Diagnosis: Ectopic pregnancy. Chief Complaint: Lower abdominal pain. HISTORY OF PRESENT ILLNESS: The patient states she has been having vaginal bleeding more like spotting over the past month. She denies the chance of pregnancy although she
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Medical transcription the free encyclopediaMedical transcription‚ also known as MT‚ is an allied health profession‚ which deals in the process of transcription‚ or converting voice-recorded reports as dictated by physicians or other healthcare professionals‚ into text format. History Evolution of transcription dates back to the 1960s. The method was designed to assist in the manufacturing process. The first transcription that was developed in this process was MRP‚ which is the acronym for Manufacturing
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are no signs of infection at this time‚ 48 hours later. Patient was given a tetanus shot‚ and after discussion‚ for patient’s confidentiality reasons and due to low risk of this event‚ she will follow up with the health center where she gets her medical care for an HIV test and hepatitis titer tomorrow. She will return for any problems or complications. She was
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Dr. Adam’s dictation dated 04/03/08 Patients name: Diane G. Baron D.O.B: 09/07/1935 Age: 72 Sex: Female Subjective: Diane is here today with complaints of sinus symptoms‚ cough‚ there is a lot of pressure in her face‚ post nasal drainage. She denies any sore throat‚ no fever or chills. She states she’s coughing up quite a bit of white flam. She states at night sometimes she has to sit up‚ otherwise she starts coughing when she lies flat. She denies any night sweats; she is currently on combovent
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OPERATIVE REPORT PREOPERATIVE DIAGNOSIS Left carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS Left carpal tunnel syndrome. OPERATION Left carpal tunnel decompression. ANESTHESIA IV regional. PROCEDURE FINDINGS The left transverse carpal ligament was moderately thickened‚ and it was causing moderate compression of the left median nerve in the carpal tunnel. DETAILS OF PROCEDURE The patient was brought conscious to the operating room and placed on the operating table in the supine
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known or spoken of in general is Medical Transcription. It is often confused with medical records and general dictation‚ but Medical Transcription is a specialty in a class of its own. Of all the medical branches that the general public has knowledge of‚ Medical Transcription shows as a big blank in most of our minds. Most MT departments are located within the Health Information Management section of a hospital or clinic‚ but some are located outside of medical facilities and are a business that
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The future of medical transcription The future of medical transcription Many training for the field of medical transcription are in fear of choosing a career that may no longer hold value in the healthcare industry. Due to the Health Information Technology for Economic and Clinical Health (HITECH) Act‚ the United States health care system is making an industry-wide movement towards an electronic environment for health information management (Office of the National Coordinator for Health Information
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RESEARCH PROJECT (Medical Transcription 1‚ HIT 207 Background As a medical transcriptionist‚ you’ll work with many different medical specialties. It’s important to have a basic knowledge of medical specialties so you can better understand the medical transcription submitted. Procedure 1. Identify eight medical specialties. List the specialties and write two paragraphs about seven specialties. 2. From the eight specialties you cover‚ select one that particularly interests you. For
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HISTORY AND PHYSICAL EXAMINATION Good morning this is Alex McClure‚ MD dictating PATIENT NAME: Brenda c. Seggerman PATIENT ID: 903321 Date of Admission: 3/27/2012 EMERGENCY ROOM Physical: Alex McClure. MD Admitting diagnosis: Egtopic pregnancy Chief Complain: The patient presents in the emergency this morning‚ complaining of lower abdominal pain. HISTORY OF PRESENT ILLNESS: the patient states that she has been having vaginal bleeding more like spotting over the past month
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AND PHYSICAL EXAMINATION or EMERGENCY DEPARTMENT TREATMENT RECORD Patient Name: Brenda C. Seggerman Patient ID: 903321 DOB: Age: 35 Sex: F Room No.: Date of Admission/Date of Arrival: 3/27---- Admitting /Attending Physician: Alex McClure M.D. Admitting Diagnosis: Ectopic Pregnancy Chief Complaint: The patient presents in the emergency room this morning‚ complaining of lower abdominal pain. History of Present Illness: The patient states that she has been having vaginal bleeding
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