Last week ended abruptly when I was unable to access any further modules. Unfortunately, this happened on a weekend when there was no staff present, so I had to wait for Monday morning. I received access at 7:54 am on Monday morning, which was very early so I was pretty happy with that. It took me about an hour to complete the keyboarding techniques module; most of this was spent on the needlessly difficult module test.

It is as though they set their students up for failure by making the module-end tests very difficult to understand or providing many correct answers, but asking us to answer with the most correct answer… Akin to nursing school with the exception that this is not about critical thinking in this context and the passing grade is 90% or above with only one attempt at the test, so if you misinterpret their questions which I swear some are blatantly incorrect, you are out of the program. Not overly fair for a college to do to its students when the students are paying for this education and services.

With that said, I now have two more modules left to complete before hitting the first milestone. The remaining modules are:

• Grammar & Style
• Medical Report Formatting

It is now 1:03 pm and I have been waiting since 9:20 am to get access to the next module. Apparently, this is a thing that happens frequently. I am getting the sense that my ability to complete this program quickly will be fully dependant on my instructor’s ability to grant me access in a timely fashion.

Keyboarding Techniques

December 13th, 3:04 pm. My bad. I did not complete the Keyboarding Techniques modules in full. I had the checkmark on my outline, so I thought I had completed the module. The last part of the module was a link to WARP studio, where transcription files are located.

I saw an empty queue when I opened the WARP page, so I didn’t actually think that there was anything left for me to do there.

I contacted my instructor and received a response within thirty minutes, where she directed me to a link on the WARP page. The link allowed me to download transcripts to begin working on for practice. There were seven document files for me to transcribe, edit, submit, then self-assess.self-grade. These files were just random tidbit information files that were not medical records — this is the part of the program that lets us get used to listening to speech and transcribing the file using the tools available to us. In most students’ cases, they would have a foot pedal for this, however, mine has not yet been shipped. That is of no fault of the schools — this is just because I jumped right into the program without any couth.

With the transcription files at my disposal, I was able to complete the transcriptions and thus complete the Keyboarding Techniques module that same evening.

Grammar and Style

For the Grammar and Style module, the module content was pretty straight-forward, though there are some interesting rules for comma placement and the use of written numbers versus actual numbers that I am still getting the hang of. This module ended with 8 transcripts, which I was able to complete on December 14th — so roughly one full date on that module.

Medical Report Formatting

The next module was Medical Report Formatting, which introduced us to the BOSS4, which is the Medical Transcriptionist’s bible, so to speak. The Book of Style & Standards for Clinical Documentation. As a CanScribe student, we get one year of access to the online version of the book via VitalSource.com. This book is easy to use as a resources as the online version has a search button, so we can skip to the appropriate chapters and pages that we need to review.

The biggest learning takeaway from this module was the overall formatting of a medical transcription report. This isn’t overly new for me, having worked in acute care for so long but it was good to reinforce the knowledge in a more concrete way. I am still getting the hang of some of the items as there is more than one way to do it, so there are often a lot of “differences” in my submitted transcript versus the transcript that it used as our answer key.

The hardest part is determining which differences are acceptable variations and which are blatantly incorrect. As this is self-graded, it can be frustrating to not know the actual answer. The instructor is available to help clarify during school hours, however.

Example document:

[Name] returns today for a physical exam. Either the next sentence begins here or in a new paragraph. This sentence usually has a brief medical history of the patient, then goes into relevant history of presenting illness.

On exam today the patient is well-appearing. Sometimes this is in a new paragraph, sometimes it is in the introductory paragraph still. Blood pressure is 120/80. Pulse is 64. Sometimes there is a colon between, sometimes there is a comma.
HEENT: Neck is supple, with no mass, no JVD, no bruits.
Chest is clear.
Cardiopulmonary: No murmur, no gallop.
Abdomen: Soft, nontender, no mass, no bruit.
Extremities: No edema.

ASSESSMENT
1. Current issue. Any tidbits of info here.
2. Hypertension. Well controlled with medication and diet.
3. Another issue, well controlled. Sometimes a comma is used to separate the diagnoses from the related information.

PLAN
Added a prescription for Xanax, which has been sent to pharmacy. Patient will return in 4-6 months’ time.

Quick Tips For or From Me

• Nontender is often dictated as “nontend,” which took me forever to hear.
• Exam points can be written in narrative or in a list-style.
  • (a) Chest is clear. Abdomen is soft, nontender, no mass, no bruit.
  • (b) Chest: Clear.
    Abdomen: Soft. Nontender. No mass. No Bruit.
• I have a hard time distinguishing between bruit and bruits — aloud, they sound so similar and there isn’t often an indication within the context of a sentence to allow one to decipher if it is plural or singular. I default to bruits as we are ruling out bruits, rather than a singular bruit.

There were 6 transcriptions for this module and I was able to complete by 1:10 pm on December 15th, bringing me to the first Milestone of the CanScribe’s Medical Transcriptionist program.

I started this program on a Friday, and with this blog post I have taken us well into the second week of this self-paced program.

I am going to split the next week into the dates of December 15th (end) to December 24th for Week 3. Stay tuned!