COURSE SYLLABUS

 

COURSE IDENTIFICATION

 

Course Prefix/Number:                      ALMT 237

Course Title:                                         Medical Transcription IV (Surgical)

Division:                                                Outreach and Workforce Development

Program:                                               Medical Transcription

Credit Hours:                                        Five (5)

Initiation/Revision Date:                   Fall 2006

 

CLASSIFICATION OF INSTRUCTION

 

Vocational

 

COURSE DESCRIPTION

 

Surgical Transcription will include a comprehensive study of surgical techniques, instruments, and operative procedures by body system and a continuation of laboratory tests and diagnostic procedures that includes advanced medical imaging procedures and anatomic pathology.  This course will include physician-dictated surgery reports organized by medical specialty. 

 

PREREQUISITES

 

1. A mastery of English and spelling as evidenced by completion of English Composition I and/or a passing score on the Compass test.

2. A minimum typing speed of 50 words per minutes as evidenced by the Mavis Beacon or equivalent.

3. Passing grade of B or higher in Medical Transcription III.

4. Or instructor permission.

 

TEXTS

 

**Note: Text #1 is the only additional text required beyond what was needed in Beginning Medical Transcription I, II, and III.

 

Surgical Technology Principles and Practice, 3rd ed. By Joanna Ruth Fuller, 1994.  Published by W.B. Saunders Co.

 

Laboratory Tests and Diagnostic Procedures in Medicine, by John H. Dirckx, M.D., 2004.  Published by Health Professions Institute.

 

The Medical Transcription Workbook, 1999.  Published by Health Professions Institute.

 

Dorland’s Illustrated Medical Dictionary, latest edition.  Published by Elsevier or Stedman’s Medical Dictionary, latest edition.  Published by Lippincott Williams & Wilkins.

 

Saunders Pharmaceutical Word Book, 2006, by Drake and Drake.  Published yearly by Elsevier.

 

Stedman’s Abbreviations, Acronyms & Symbols, 2nd ed.  Published by Lippincott Williams & Wilkins.

 

The AAMT Book of Style for Medical Transcription, 2nd ed.  Published by AAMT.

 

A standard collegiate dictionary.


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**Optional – Stedman’s Plastic Surgery, ENT, and Dentistry Words, current edition.  Published by Lippincott, Williams & Wilkins. 

 

**Optional – Stedman’s Surgery Words, current edition.  Published by Lippincott, Williams, &Wilkins.

 

 

TRANSCRIPTION MATERIALS

 

**Optional – Needed if desire to type at home.

 

**The SUM Program Intermediate Medical Transcription Unit (available on CD-ROM or standard-size cassette tapes).

 

**WAV pedal or cassette player with pedal.

 

Three-ring notebook.

 

Several disks for saving transcription files.

 

OTHER POSSIBLE INSTRUCTIONAL MEDIA

 

Overhead projector, transparencies, various class handouts, computer simulation.

 

COURSE OUTCOMES AND COMPETENCIES (as Required)

 

I.             Surgical Procedures: The student will demonstrate a thorough knowledge of surgical techniques, instruments, and operative procedures by body system as evidenced by unit assessments.

A. Identify common surgical procedures for each body system.

B. Describe the role of member of the healthcare team in the operating and recovery rooms.

C. Describe and sequence the steps commonly taken to prepare a patient for surgery.

D. List common suture materials, suture techniques, and dressings.

E. Identify common surgical instruments and describe their use.

F. Describe the steps involved in selected surgical procedures for each body system.

G. Define common abbreviations for surgeries by body system.

H. Spell and pronounce common surgical procedures.

 

II.            Laboratory Tests and Diagnostic Procedures in Medicine II: The student will demonstrate a thorough knowledge of advanced medical imaging procedures and anatomic pathology, methodology, indications, and range of results as evidenced by unit assessments.

A. List the indications and diagnostic and/or surgical uses of thoracoscopy, mediastinoscopy, laparoscopy, culdoscopy, and arthroscopy.

B. Discuss the basic principles of contrast radiography and describe the applications and limitations of contrast examinations of the upper and lower digestive system and biliary tract, the genitourinary system, and cerebral, coronary, and pulmonary angiography.

C. Explain how computed tomography differs from standard diagnostic radiography, list advantages and applications of CT, and discuss the use of contrast media in CT.

D. Discuss the basic principles, advantages and disadvantages, and application of diagnostic ultrasonography in obstetrics and cardiology.

E. Describe how magnetic resonance imaging works and explain its advantages and disadvantages.


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F. Define radioisotopes and tell how they are applied in nuclear imaging and explain how nuclear imaging differs from all other imaging methods.

G. Describe the gross and microscopic structure of the human body, the structure and function of cells, and the distinguishing features of basic tissue types.

H. Outline the procedure for preparing stained sections of tissue for microscopic examination and discuss the basic techniques and diagnostic roles of cytologic studies, biopsies, and autopsies.

I. Explain the pathologic consequences of developmental, growth, and nutrition disorders; inflammation, infection, and allergy; atrophy, degeneration, and necrosis in circulatory disorders; and benign and malignant neoplasms.

J. Distinguish formed elements of the blood and describe basic laboratory tests pertaining to them.

 

III.          Intermediate Medical Transcription Practice: The student will demonstrate a thorough knowledge and ability to transcribe physician-dictated surgery reports organized by medical specialty as evidenced by unit assessments.

A. Select the correct format for a dictated surgical report.

B. Demonstrate the proper use of reference materials.

C. Transcribe operative reports, diagnostic studies, and surgical procedure notes.

D. Edit the transcript to correct obvious grammatical and punctuation errors.

E. Identify obvious medical inconsistencies.

F. Produce a final, neat, error-free transcript.

G. Increase transcription seed and productivity throughout the course.

 

 

COURSE OUTLINE

 

I.             Section 1 – Cardiovascular/Thoracic Surgery

Surgical Procedures:

                A. Introduction to curse and overview of contents.

                B. The operating room and staff.

                C. Aseptic technique.

                D. Anesthesia methods.

                E. Transporting and positioning the patient.

                F. Preparation of the surgical site.

                G. Wounds and wound closure.

                H. Hemostasis.

Laboratory Tests and Diagnostic Procedures: Endoscopic Examinations Requiring Incisions

                A. Thoracoscopy.

                B. Mediastinoscopy.

                C. Laparoscopy.

                D. Culdoscopy.

                E. Arthroscopy.

Intermediate Medical Transcription Practice:

                A. Introduction of course and overview of contents.

                B. Report formats for operative reports, diagnostic studies, and procedure notes.

                C. Review of cardiovascular surgery.

                D. Review of thoracic surgery.

E. Transcription of physician-dictated cardiovascular and thoracic surgery reports.


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II.            Section 2 – Cardiovascular/Thoracic Surgery

                                Surgical Procedures:

                                                A. Surgical instruments.

                                                B. Cardiothoracic surgery.

                                Laboratory Tests and Diagnostic Procedures:

                                                *No assignments for this section.

                                Intermediate Medical Transcription Practice:

                                                A. Review of cardiovascular surgery.

                                                B. Review of thoracic surgery.

C. Transcription of physician-dictated cardiovascular and thoracic surgery reports.

 

III.          Section 3 – Gastrointestinal Surgery

Surgical Procedures:

                                                A. Open gastrointestinal surgery.

                                Laboratory Tests and Diagnostic Procedures: Computed Tomography

                                                A. How computed tomography differs from standard radiography.

                                                B. Advantages and applications of computed tomography.

                                                C. Use of contrast media in computed tomography.

                                Intermediate Medical Transcription Practice:

                                                A. Review of gastrointestinal surgery.

                                                B. Transcription of physician-dictated gastrointestinal surgery reports.

 

IV.          Section 4 – Gastrointestinal Surgery               

                                Surgical Procedures:

                                                A. Laparoscopic gastrointestinal surgery.

                                Laboratory Tests and Diagnostic Procedures:

                                                *No assignments for this section.

                                Intermediate Medical Transcription Practice:

                                                A. Review of gastrointestinal surgery.

                                                B. Transcription of physician-dictated gastrointestinal surgery reports.

 

V.            Section 5 – Genitourinary Surgery

                                Surgical Procedures:

                                                A. Urinary surgery.

                                                B. Male reproductive system surgery.

                                Laboratory Tests and Diagnostic Procedures: Ultrasonography

                                                A. Principles of ultrasonography.

                                                B. Obstetrical ultrasonography.

                                                C. Echocardiography.

                                Intermediate Medical Transcription Practice:

                                                A. Review of urological surgery.

                                                B. Review of male reproductive system surgery.

                                                C. Transcription of physician-dictated genitourinary surgery reports.

 

VI.          Section 6 – Genitourinary Surgery

                                Surgical Procedures:

                                                A. Laser technology and use.

                                Laboratory Tests and Diagnostic Procedures:

                                                *No assignments for this section.


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                                Intermediate Medical Transcription Practice:

                                                A. Review of urological surgery.

                                                B. Review of male reproductive system surgery.

                                                C. Transcription of physician-dictated genitourinary surgery reports.

 

VII.         Section 7 – Head and Neck Surgery

                                Surgical Procedures:

                                                A. Thyroid surgery.

                                                B. Ear, nose, throat, and mouth surgery.

                                Laboratory Tests and Diagnostic Procedures: Magnetic Resonance Imaging

                                                A. How magnetic resonance imaging works.

                                                B. Advantages and disadvantages of MRI.

                                Intermediate Medical Transcription Practice:

                                                A. Review of neck surgery.

                                                B. Review of ear, nose, and throat surgery.

                                                C. Review of eye surgery.

                                                D. Transcription of physician-dictated head and neck surgery reports.

 

VIII.       Section 8 – Head and Neck Surgery

                                Surgical Procedures:

                                                A. Eye surgery.

                                Laboratory Tests and Diagnostic Procedures:

                                                *No assignments for this section.

                                Intermediate Medical Transcription Practice:

                                                A. Review of neck surgery.

                                                B. Review of ear, nose, and throat surgery.

                                                C. Review of eye surgery.

                                                D. Transcription of physician-dictated head and neck surgery reports.

 

IX.          Section 9 - Neurosurgery

                                Surgical Procedures:

                                                A. Neurosurgery.

                                Laboratory Tests and Diagnostic Procedures: Nuclear Imaging

                                                A. Concepts of nuclear imaging.

                                                B. What is a radioisotope.

                                                C. How nuclear imaging differs from all other imaging.

                                                D. Positron emission tomography.

                                                E. SPECT scan.

                                                F. Ventilation-perfusion lung scan.

                                                G. Bone scintigraphy.

                                Intermediate Medical Transcription Practice:

                                                A. Review of neurosurgery.

                                                B. Transcription of physician-dictated neurosurgery reports.

 

X.            Section 10 – OB/GYN Surgery

                                Surgical Procedures:

                                                A. Gynecological surgery.

                                                B. Obstetrical surgery.

                                Laboratory Tests and Diagnostic Procedures: Normal Anatomy and Physiology

                                                A. Gross and microscopic structure of human body.

                                                B. Structure and function of cells.

                                                C. Distinguishing features of basic tissue types.


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                                Intermediate Medical Transcription Practice:

                                                A. Review of gynecological surgery.

                                                B. Review of obstetrical surgery.

                                                C. Transcription of physician-dictated obstetrical reports.

                                                D. Transcription of physician-dictated gynecological reports.

 

XI.          Section 11 – OB/GYN Surgery

                                Surgical Procedures:

                                                A. Surgical routines and emergencies.

                                Laboratory Tests and Diagnostic Procedures:

                                                *No assignments for this section.

                                Intermediate Medical Transcription Practice:

                                                A. Review of gynecological surgery.

                                                B. Review of obstetrical surgery.

                                                C. Transcription of physician-dictated obstetrical reports.

                                                D. Transcription of physician-dictated gynecological reports.

 

XII.         Section 12 – Orthopedic Surgery

                                Surgical Procedures:

                                                A. Orthopedic surgery.

Laboratory Tests and Diagnostic Procedures: Procedures and Practices in Anatomy and Physiology

                                                A. Staining procedures of tissue for microscopic examination.

B. Basic techniques and diagnostic roles of cytologic studies, biopsies, and autopsies.

                                Intermediate Medical Transcription Practice:

                                                A. Review of orthopedic surgery.

                                                B. Transcription of physician-dictated orthopedic surgery reports.

 

XIII.       Section 13 – Orthopedic Surgery

                                Surgical Procedures:

                                                A. Microbiology.

                                                B. Acquired immunodeficiency syndrome (AIDS).

                                Laboratory Tests and Diagnostic Procedures:

                                                *No assignments for this section.

                                Intermediate Medical Transcription Practice:

                                                A. Review of orthopedic surgery.

                                                B. Transcription of physician-dictated orthopedic surgery reports.

 

XIV.       Section 14 – Plastic Surgery

                                Surgical Procedures:

                                                A. Plastic and reconstructive surgery.

Laboratory Tests and Diagnostic Procedures: Pathologic Change and Pathologic Diagnosis

                                                A. Pathologic consequences of developmental, growth, and nutrition disorders.

                                                B. Pathologic changes in inflammation, infection, and allergy.

C. Pathologic changes in atrophy, degeneration, and necrosis in circulatory disorders.

D. Pathology of benign and malignant neoplasm.

                                Intermediate Medical Transcription Practice:

                                                A. Review of plastic surgery.

                                                B. Review of breast surgery.

                                                C. Transcription of physician-dictated plastic surgery reports.


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XV.         Section 15 – Plastic Surgery

                                Surgical Procedures:

                                                A. Breast surgery.

                                Laboratory Tests and Diagnostic Procedures:

                                                *No assignments for this section.

                                Intermediate Medical Transcription Practice:

                                                A. Review of plastic surgery.

                                                B. Review of breast surgery.

                                                C. Transcription of physician-dictated plastic surgery reports.

 

INSTRUCTIONAL METHODS

 

1.       Lecture

2.       Audio-Visual aids

3.       Example and demonstration

4.       Physician dictation

5.       Revision of dictation

6.       Conference

7.       Tests

8.       Unannounced requirements, including unannounced tests, possible

9.       Paper/pencil assignments

 

STUDENT REQUIREMENTS AND METHOD OF EVALUATION

 

Evaluation of student performance is determined primarily from results of vocabulary notebook, examinations, basic skills tests, terminology tests, homework, and transcription lab work. Class attendance and participation is a must.  There will be a significant final exam.

 

GRADING SCALE

 

Because of the necessity of error-free documents and the demand of employers requiring 96% accuracy or higher, the following grading scale is used:

 

                95-100%               A

                89-94%                  B

                83-88%                  C

                76-82%                  D

                75% or below       F

 

Written assignments            15%

Vocabulary Notebook        15%

Terminology/Skills tests     20%

Dictation practice                                15%

Dictation tests                      35%

 

ASSESSMENT OF STUDENT GAIN

 

Student gain will be assessed based on performance on written assignments, tests, and the progress of dictation skills.


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Attendance Policy

 

Absences that occur due to students participating in official college activities are excused except in those cases where outside bodies, such as the State Board of Nursing, have requirements for minimum class minutes for each student. Students who are excused will be given reasonable opportunity to make up any missed work or receive substitute assignments from the instructor and should not be penalized for the absence.  Proper procedure should be followed in notifying faculty in advance of the student’s planned participation in the event.  Ultimately it is the student’s responsibility to notify the instructor in advance of the planned absence.

 

Unless students are participating in a school activity or are excused by the instructor, they are expected to attend class.  If a student’s absences exceed one-hundred (100) minutes per credit hour for the course or, in the case of on-line or other non-traditional courses, the student is inactive for one-eighth of the total course duration, the instructor has the right, but is not required, to withdraw a student from the course.  Once the student has been dropped for excessive absences, the registrar’s office will send a letter to the student, stating that he or she has been dropped.  A student may petition the chief academic officer for reinstatement by submitting a letter stating valid reasons for the absences within one week of the registrar’s notification.  If the student is reinstated into the class, the instructor and the registrar will be notified. 

Academic Integrity

NCCC expects every student to demonstrate ethical behavior with regard to academic pursuits.  Academic integrity in coursework is a specific requirement.  Definitions, examples, and possible consequences for violations of Academic Integrity, as well as the appeals process, can be found in the College Catalog, Student Handbook, and/or Code of Student Conduct and Discipline.

 

CELL PHONE POLICY

 

Student cell phones and pagers must be turned off during class times. Faculty may approve an exception for special circumstances.

 

NOTE:

 

Information and statements in this document are subject to change at the discretion of NCCC.  Changes will be published and made available to the students.

 

NOTE: If you are a student with a disability who may need accommodation(s) under the Americans with Disabilities Act (ADA), please notify the Director of Advising and Counseling, Chanute Campus, Student Union, 620-431-2820 ext 280 or the Dean, Ottawa Campus, 785-242-2607 ext 312, as soon as possible.  You will need to bring your documentation for review in order to determine reasonable accommodations, and then we can assist you in arranging any necessary accommodations.