Medical Transcription Grammar
Speech recognition has permanently changed medical transcription and in most cases, for the better. However, with the advent of this new technology, critical patient safety errors are on the rise. One of the categories in patient medical records where these errors are highest is in laboratory or diagnostic data.
Why would this happen? Speech engines can't think and as advanced as the technology is, it simply spits out what it "thinks" it hears. Medical transcriptionists today in many venues are editors rather than typing the entirety of the dictated reports.
The result of the change in the MT job description has made grammar and punctuation of medical reports even more important than it was years ago. While some may argue that point and say that grammar and punctuation don't matter, they do when you're talking about documenting accurate information in a patient's chart--whether physical or an electronic medical record.
How a lab test is transcribed matters a great deal. The placement of a period or a decimal can dramatically change the meaning of the lab result for instance. Accuracy of the components listed in blood work is also vital.
Probably secondary only to the CBC (acronym for complete blood count), the BMP and the CMP are going to show up on a daily basis in the course of the medical transcriptionist's day.
The BMP (or basic metabolic panel) and the CMP (or comprehensive metabolic panel) are vital to patient care because these assays note values for anything from diabetes to renal failure all in one blood test.
Let's take a look at the components of the BMP and CMP and how they should be properly notated in medical transcription.
Punctuation and Sentence Structure for MT
It is very important for the medical transcriptionist in today's marketplace to understand about punctuation and sentence structure.
The most important things to remember when it comes to punctuation and grammar in transcription:
- Keep like things together--this means do not combine BMP and CMP values with CBC values. Create separate sentences.
- Always listen for dictation of verbs, prepositions and conjunctions. If they are dictated, the sentence structures should reflect that as well as following the rule about keeping like items together.
- Short and sweet sentences are perfect for vital signs and lab data transcription.
- Clipped sentences are also great for noting lab or diagnostic results.
- The MT should never try to make complete sentences out of dictation that has been purposefully dictated in the clipped sentence style. It muddies up the report because usually the information is dictated this way for ease of reading.
Transcribing Laboratory Data - BMP
As noted above, BMP stands for "Basic Metabolic Panel" and does not ever have a numerical value associated with it. It is simply the name of the panel that has 7 or 8 different electrolyte tests on it. (Sometimes the calcium is left off reducing the total components to 7 from 8.)
It is also referred to as a Chem-7 (or Chem-8).
CRITICAL NOTE: A BMP is never associated with a number. If you hear what sounds like “BMP” dictated and there is a numerical value dictated for it, it is instead a "BNP." A BNP is a cardiac enzyme test and always has a number associated with it. Substitution of "BMP" for "BNP" would constitute a critical patient safety error. This illustrates the importance of knowing the components of lab tests and also what the acronyms mean in pathological and laboratory medicine.
What Does the BMP Consist of and What Does it Test For?
The BMP is a battery of tests usually ordered to assess quickly things like glucose levels or kidney function levels. It is also used to measure the level of salt in the blood (sodium) or potassium. It is also called the electrolyte panel or in short form "lytes."
This test is usually ordered on routine physicals but may also be ordered repeatedly in the treatment of serious conditions such as hypo- or hyperglycemia or renal failure.
-Components of the BMP:
- bicarbonate (also called CO2, carbon dioxide or "bicarb")
- BUN (blood urea nitrogen)--always capitalized
- calcium ** not always dictated
Usually BMPs are dictated in the order as noted above.
Transcription Note: As a style preference, if "CO2" is dictated followed immediately by a number, it is most common to see "of" inserted--so CO2 of 26 even if "CO2 26" was dictated. Why? This makes the numerical value of the component easier to read at a glance.
This practice is most common in MT curriculums but can also be part of the style requirements for a facility or transcription service. It is a matter of preference and not really one of which way is right or wrong.
Laboratory Data Transcription - CMP
If more tests are felt necessary than covered on the BMP, the CMP or Comprehensive Metabolic Panel will be ordered which includes the above 7 or 8 tests plus another 6 tests:
-Components of the CMP:
- bicarbonate or CO2
- calcium if included
- total protein
- ALP (many times called alkaline phosphatase or "alk phos")
- ALT (also called SGPT)
- AST (also called SGOT)
As you can see, the comprehensive metabolic panel is just a ramped up version of the basic metabolic panel but will provide much more information to the reader.
It is also referred to as the Chem-14.
Transcription Formatting for the BMP and CMP
- Make sure you are dealing with a BMP or a CMP (dependent upon the number of subtests named).
- Follow good grammar practices as above noting if complete sentences or clipped sentences.
- There is no limit to the number of clipped dictated numerical values that can be dictated in one sentence. However, do not combine the CBC for instance with the dictated values for BMP or CMP in one sentence.
Remember: Like values should stay with like values for ease of reading and interpretation.
EXAMPLE: LABORATORY DATA: On admission, the BMP showed sodium 140, potassium 3.7, chloride 104, CO2 26, glucose 302, BUN 27, creatinine 0.8, calcium 8.5.
Analysis: Here, the beginning information was dictated "On admission, the BMP showed" but then the elements of the test were simply dictated in clipped style. They should be left as dictated. (Unless preference indicated that you should insert the word "of" after "CO2."
In another instance, you might have the following.
EXAMPLE: LABORATORY DATA: Sodium 138, potassium 4.2, chloride 110, CO2 of 26, BUN 27, creatinine 0.7, glucose 82, calcium 9.5.
Analysis: There is no verb and all values are clipped. There is no reason to insert a conjunction such as “and." There is no reason to insert information such as “BMP” if not dictated. The important thing to note here is that the “like” values (electrolyte panel elements) are all grouped together.
In yet another report, you could encounter something like this:
EXAMPLE: LABORATORY DATA: CMP on admission showed sodium to be 138, potassium 4.2, chloride 110, CO2 of 26, BUN 27, creatinine 0.7, glucose 82, calcium 9.5. Albumin was 3.4, total protein 7.2, ALP 76, ALT 72, AST 92, bilirubin 0.2.
Analysis: Here we had several complete sentences so they would be broken up. You could also separate them with a semicolon but it’s easier just to put complete sentences separate as they are easier to read.
In the case of the BMP and the CMP, you do not have subcategories of the tests so you do not have to worry about associating the right components of the individual items with its correct category. You simply have to make sure you know all the components that make up the two electrolyte panels and why they differ.
You should also be aware of normal levels for each component of the BMP or CMP and flag appropriately any discrepancies or questionable values with a _____ (5 underscores) before the questioned value.
Transcribing Diagnostic Data in a Report
Now that you have learned about the components of the BMP and the CMP, it's important to note how the information from these two tests would be incorporated into an entire paragraph detailing other important diagnostic information.
Here is a typical sample of a detailed laboratory section for a discharge summary.
EXAMPLE: LABORATORY AND DIAGNOSTIC DATA: The patient had a normal EKG upon admission. Chest x-ray showed patchy left lower lobe density. CBC: Hemoglobin 14.4, hematocrit 45.3 and MCV 92.1. White blood count 11.6 with 2 bands, 70 lymphs; 228,000 platelets. Sodium was 139, potassium 3.2, chloride 106, CO2 of 28, BUN 17, creatinine 0.9, glucose 115 with a calcium of 8.7. Albumin was 3.1, total protein 7.1, alkaline phosphatase (dictated alk phos) 112, ALT 23, AST 14, and total bilirubin 0.3.
Analysis: A new sentence was made starting with albumin because the verb "was" was dictated. Notice how all "like" tests were kept in their own sentence, however. It makes the information easier to read and indicates to someone in a logical fashion which tests were done and what parts of the test might be normal or abnormal.
Remember: Not all dictators list all components of laboratory or diagnostic tests. For instance, someone might dictate the results of a CMP only mentioning the ALP and ALT because they were elevated.
The accuracy of the medical record is dependent upon the skills of the medical transcriptionist and his or her ability to recognize correct values and to flag incorrect values or components.
The integrity of a patient's medical record is only as good as the MT who's committing it to permanence by transcribing it. The MT plays a pivotal role in reducing critical patient safety errors and lab values are at the top of the list for requiring accuracy.
For more information on lab tests and explanations of other lab procedures, check out labtestsonline.org.
Audrey Kirchner (author) from Washington on August 03, 2012:
Lela - I hear you - I don't think they'll ever get rid of some of us as "interpreting" the voice recognized dictation turns out to be way worse than actual dictated files that we transcribed by hand. It also turns out that it is WAY easier for MTs to make mistakes - which should make EVERY patient in the word feel SO GOOD! It is a brain thing or so they tell me~~~ You see the word on the page and it "looks right" so it must be, right?? Too bad it was the entirely WRONG medication allergy or the WRONG medication or lab value! It is becoming like being an air traffic controller to tell you the truth....way stressful but weirdly, I like the challenge of getting every record as right as it can be. Lots more stress though and we have "come so far???" I always say that progress doesn't mean that the job just got easier and definitely this has proven to be the case with MT work.
Lela from Somewhere near the heart of Texas on August 03, 2012:
With the advent of computer sound files, I wonder why the medical industry still needs all the paper? Not to put you out of a job or anything, but sound files or even video files make more sense today.
I always hated all the paper in the lab. The storage and retrieval was horrendous!
Audrey Kirchner (author) from Washington on August 03, 2012:
Thanks BJ - I know the feeling~
drbj and sherry from south Florida on August 03, 2012:
After reading this, Audrey, I've decided you see,
That Medical Transcription is not for me.
Just reading this hub
With the words above
Has forced my brain to run on empty!