Many believe that the “old-fashioned” word books or other reference books for medical transcription have become dinosaurs in the age of the Internet, but I disagree. Yes — you can google phrases and the like that stump you, but I STILL find myself pulling one of my many specialty word books off the shelf and thumbing through it. If you can’t make out one piece of the phrase, you may well be stuck for many, many minutes furtively trying to find an answer on Google or other search sites–perhaps coming up totally empty-handed … and still frustrated. But, with a word book, say, for example, it’s a type of cell in the specialty of urology, you can pull out your Stedman’s GI/GU Word Book, look under cell and voila — what sounded like Cupper cells or Kupper cells or whatever….is actually Kupffer cells. Try googling that one when you have such a vague idea (and a marble-mouthed dictating doctor) to go on. I have to admit that if I were starting out this very minute in this career, I’m not sure I’d have the extensive library of word books I own now, but there’s rarely a working day that passes that I haven’t used at least 1 or 2 of them to help me out of a pinch and a blank. The drug books are sometimes still the quickest way to verify a dosage or use of a medication — and a lab reference book if you want to quickly and accurately learn the reference range or uses for a specific lab test. If you’re interested (even if you’re not, I’m doing it anyway) — here’s my list of current reference books:
Laboratory Test Handbook and Word Index
Dorland’s Pocket Medical Dictionary
Vera Pyle’s Current Medical Terminology
Medical Abbreviations and Eponyms — Sloane (abbreviations are VERY hard to reference on the Web!)
Saunders’ PharmaceuticalWord Book 2005
Dermatology & Immunology
Cardiology & Pulmonary
Psychiatry, Neurology, Neurosurgery
Ophthalmology
Orthopedic & Rehab
Tessier’s Surgical Word Book (the latest edition of this has more spelling errors than I’d prefer)
Organisms & Infectious Disease
GI & GU
Oncology
Plastic Surgery/ENT/Dentistry
AAMT Book of Style
Dorland’s Pocket Medical Dictionary
Stedman’s Medical Dictionary
The problem with typing up records is data security and transmission. The purpose of HIPAA was to improve the efficiency and effectiveness of the healthcare system through the development of established health data standards and requirements for the transmission and storage of electronic health information. Currently, however, a select few EMR and medical transcription services comply with these standards. We need to create a licencing mechanism to ensure that companies are indeed HIPAA compliant, similar to how manufacturers get ISO-9001 certified. Otherwise, the act just turns into a marketing tag line for companies.