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It is transcribing
actually what doctor means.
IMPRESSION am I cute?
IMPRESSION: Myocardial infarction (MI), acute.
neck no carotid bruise cervical limb denopathy no GVD period
PHYSICAL EXAMINATION: Neck: No carotid bruits or cervical
lymphadenopathy. No jugular venous distention (JVD).
D: pre and postop diagnosis appy
PREOPERATIVE DIAGNOSIS: Appendicitis.
POSTOPERATIVE DIAGNOSIS: Appendicitis.
MTs are also called documentation specialist, clinical documentation
expert, MLS=medical language specialist, MLQA, MCQA, Editor,
eScription editor, etc.
SKILLSET NECESSARY IN MT
1.
2.
3.
4.
5.
6.
Ability to focus/concentration/involve for long time and must be
able to have meticulous attention for minute details.
7.
Must have investigative mind and able to find alternatives for most
of words to make sure that the words fit into context of sentence.