Medical transcription consists of much more than transcribing dictated reports. As a specialist in the workers’ compensation field, working for orthopedic surgeons, I review medical records before a patient is examined for a work-related injury claim. When a worker is injured on the job and makes a claim, litigation is involved. Sometimes the claims are rejected and the injured worker (called an applicant) will hire an attorney to represent him or her. The insurance company will also have its own attorney or attorneys. There are different types of examinations such as Independent Medical Examinations (IMEs), Agreed Medical Examinations (AMEs), and Qualified Medical Evaluations (QMEs). I will not go into explanation of these examinations/evaluations, but just keep these terms in mind as you continue in your medical transcription career and as you see medical reports. I will make a separate post about these at a later date, so keep on coming back to my blog.

I go through stacks of medical records and pull out the important information for the doctor, summarizing it in a particular format. The medical record reviews are short and sweet. Note that the date format is numeric. Important information is bolded to call it to the doctor’s attention.

In the example below, the patient is being evaluated for bilateral carpal tunnel syndrome (CTS). Here are a couple of entries that show how this work is done.

3/18/03 - Health Questionnaire from D. Davis, M.D. The patient is 5′6″, weighs 189 lbs., is left-hand dominant, and has a history of back and neck pain with recent hospitalization for “blackout.”

3/18/03 - Handwritten examination notes from D. Davis, M.D., revealed the patient presented with complaints of hip, neck, back, right arm pain, and carpal tunnel with a date of injury of 8/10/02. The patient had undergone an MRI scan but forgot films. Bedrest helped her back. Examination: Positive Phalen’s, right, with right thenar atrophy. X-rays of the cervical and lumbar spine were taken. Diagnoses: Right carpal tunnel syndrome; cervical spondylosis, C5-6, C6-7; advanced degenerative disc disease, L4-5 through L5-S1. Suspect patient will eventually need surgery but not now. The patient will return in three weeks.

Also, I review depositions, and job descriptions, and employee records. In short, any records that are subpoenaed by the attorney(s). This is fascinating work. It is also can be crucial to a medicolegal case.