Reference no: EM133138655

Activity: Grammar, Punctuation and Style

Assignment of Medical Transcription

QUESTION 1: Confirm the following assignment requirements and complete the transcription activity. Review the following pre-admission report details that you have received from St John's Hospital:

REPORT DETAILS:

• Patient to be admitted as an elective patient for operative treatment of a brain tumour tomorrow.
• A pre-admission workup has been performed and a report has been dictated. The information includes details about the patient, their history, examination and the type of treatment that will proceed tomorrow.
• The Pre-Admission Report must be transcribed prior to the patient being admitted tomorrow morning and a copy of the report must be available in the patient's record on admission.

CLIENT-SPECIFIC INSTRUCTIONS INCLUDE:

• Document to be transcribed and returned to client within 12 hours.
• Formatting (text features) of the document must comply with the following style guide when planning your document:
» Headings (if dictated) in BLOCK capitals (not bolded or underlined)
» Separate paragraphs (not headings unless dictated) created for the following (if dictated):
- Introduction
- Body of text
- Examination findings
- Treatment
- Conclusion
» Paragraphs created for - introduction, body of text, examination findings, treatment, conclusion (not headings, just paragraphs)
» Two spaces after a full stop, colon, question mark and an exclamation mark
» One space after a comma or semicolon
» Margins to be aligned to the left
» British/English terminology used
» No contractions (eg "I've" should be "I have")

This part of the assessment is to show you understand the purpose of the document, the requirements of the assignment, as well as to demonstrate your use of effective writing skills to develop a plan to draft text in accordance with purpose.

1a. Explain the context and the type of text that you should use in creating the workplace text for the above assignment.

1b. Identify two alternative complex text types and explain their purpose

1c. Who are you addressing your text to? What is the purpose of writing to this person? What text register should you use when communicating with a client?

1d. Read the client-specific instructions above - extract and analyse the instructions:
What does it say you have to modify with regard to grammar, punctuation and style?

1e. Now assume that you need to confirm the scope and nature of the assignment you have been set as per the scenario above, through a professional letter to the Manager of Healthcare Records - St John's Hospital. You must:
• Identify any information you require in order to complete your assignment.
• Confirm the specifications for this assignment including any formatting issues you would like to clarify
• Integrate the clients instructions and organise your letter into a logical text structure. I.e.
• Ask for help/clarification if you are unsure of anything to be able to extract and analyse information relevant to the purpose of your assignment
• Advise by when you will submit the assignment
• Any concerns that you have with the assignment
Plan how you will write your letter, with consideration for structure, layout and organisation so that it meets workplace purpose. How will you structure and format your letter? I.e. Introduction, body, number of paragraphs and a summary of what each paragraph will include.

1f. Draft your professional correspondence letter, making sure you address the manager professionally with:
• appropriate grammar
• vocabulary
• sentences
• paragraphs, and
• register.
Also ensure you sign off appropriately, with your name and (imaginary) title.

1g. Now, transcribe the Pre-Admission report in the box below. The audio file of Pre-Admission Report is available from this link. Please proofread your document to ensure the correct use of grammar and punctuation, including hyphenation, as well as the correct spelling of all medical terms, layout and organisation prior to finalising your text. You should also review and revise your draft text for accuracy, consistency, structure, cohesion and appropriateness to your client and the purpose of the text.

1h. What information can you extract and analyse about your assignment from the report you have transcribed? Who is the likely audience (i.e. who might receive a copy of the report)?

1i. How would you plan to submit this report on time while ensuring a quality outcome and meeting client expectations? List the strategies you would use to ensure a quality report while submitting it on time (consider your familiarity with the topic).

1j. What resources and reference materials would you require for this task? Write a brief description on how you would access these resources, or develop your own if required.

1k. Imagine that you were to contact other peers, colleagues and specialists to seek clarification or assistance on this assignment. How would you do this? What mode of communication and register would you use and why?

QUESTION 2:

2a. Why is it important to apply appropriate structure and format to workplace texts?

2b. The following text is a draft from a junior medical transcriptionist. Format it according to your clients instructions above, correcting spelling, grammar and punctuation.

Make sure you also apply logical text structure, sequence the ideas in a way that will make sense to your client, and produce a finalised text for your client.

Dear ___ [NAME]

His background medical history is that of an functional dyspepsia.He has had long-standing chronic periodic nausea since his teenage years. He reportedly had a gastroscopy around age 13 years in the context of school refusal secondary to abdominal pain. She has also fairly frequent relapses since that time, in particular around age 25 years and 18 years in the context of various infectious causes. Secondary to this, he suffered malnutrition related to nausea and restricted. diet and during his admission in ____ [DATE] his BMI was quite low, sitting at around 16.

I reviewed ___ [NAME] today in the Psychiatry Outpatient Clinic.

As such, my plan is:
2. I have suggested today to ___ [NAME] and his mother increasing the mirtazapine to 30 mg orally nocte. I have asked them to return to clinic in two weeks time for further review.
1. I would suggest ongoing longitudinal psychiatric review.
3. I met briefly with his mother and she discussed the need for a Centrelink assessment in regard to a disability pension. I have asked her to bring the forms if required to the next assessment and I will consider with further review whether he may require a neuropsychology assessment.

As you know, she is a single 28year old single man who receives a newstart Allowance. He currently resides with his parents in the family unit in____[PLACE]. He has none current partner and no dependents. He was formerly a university student at the ____[PLACE]. He was referred in regard to chronic depression and anxiety on a background of a possible autism spectrum disorder with a reported recent exacerbation in symptoms.

Yours sincerely,

2c. What text structure, feature and presentation could you use to make this workplace text easier to interpret?

2d. The purpose of the following exercise is to ensure that you are able to demonstrate your ability to:
• Format text with appropriate structure, layout and organisation to meet workplace purpose
• Review and revise draft text for accuracy, consistency, structure, cohesion and appropriateness to audience and purpose
• Proofread draft text for spelling, punctuation and grammar
• And finalise text for use

The following texts are extracts from draft medical reports and require editing. Please type out the text in the space provided with the correct punctuation, grammar and writing conventions.
As you know the patient is doing well now.

As you maybe aware the surgery was postponed until friday.

Because of the delay in surgery the patient has had to cancel a long planned holiday.

2e. A doctor has dictated the following sentence in fragmented form. Type out the text in the space provided with corrections to punctuation and grammar and writing conventions.

Michael has been experiencing fevers and rigors. Was prescribed some antibiotics by his GP two weeks ago. Feeling better now.

2f. The following information has been transcribed from a practitioner's notes, but there are some errors. Make sure you also apply logical text structure, sequence the ideas in a way that will make sense to your client, and produce a finalised text for your client.
Please type it out correctly in the space provided below:
No history of head injury or coma. She has not had any seizures in more than six months. He has slowing down on his alcohol use and is complaining of some dizziness, usually worsened with aquick change in position. This is a 54-year- old male with a history of seizure dissorder, likely etiology was alcohol related. She has also quiet smoking and is using the patch. He was on Neurontin, but it has been discontinued. He is currently taking doxepin 150 mg per day.

2g. What is the scope and nature of the above assignment?

QUESTION 3:

3a. Why is it important to plan a draft document first? What is the importance of reviewing that draft before finalising the document? What sort of things do you need to look for when planning your draft?

3b. What do you do if you are unsure of something when planning a draft?

QUESTION 4:

4a. Explain the term "text features" and list five text features you may use when planning to create complex workplace documents.

4b. Why do you think the following is important in preparing documents? Provide a brief explanation for each of the following processes:
• Planning
• Drafting
• Proofreading
• Reviewing
• Finalising

PROCESSES: EXPLANATION:
PLANNING
DRAFTING
PROOFREADING
REVIEWING
FINALISING

QUESTION 5:
What proofreading techniques could be adopted to ensure your report is error free? Identify two spelling strategies that you could use to review and revise complex texts.

What reference sources did you use to answer this bank of questions?

Attachment:- transcription activity.rar