How to Transcribe Diagnostic Lab Data
Medical Transcription Grammar
Though grammar and punctuation are very boring subjects to most people, in the field of medical transcription, they play a very vital role.
The trained MT makes certain diagnostic laboratory data is correctly interpreted and noted in patient charts, thus improving patient care.
How? Critical patient safety errors are on the rise today because of creative advancements in technology such as speech recognition. While no one can argue with the advantages of the electronic medical record, it still remains to be seen how many people's lives will be impacted by a system that is creating in some respects more errors than it's avoiding.
The reason is simple. A speech engine or voice recognition program does not know what correct components of lab tests to print out. No matter how much programming is done, it still cannot decipher if it was supposed to be a BNP or a BMP.
Nor is there a way (yet) for a speech engine to know what correct values are for each component of a laboratory test. That's the job of the medical transcriptionist.
Even employing MTs in today's medical documentation process, it's now much easier to miss errors on the screen even if the transcriptionist is listening intently to the dictated information.
This happens because the brain sees something as "normal" while the ear and the eye are sometimes lagging behind in terms of catching an error.
Anyone can agree that there is a vast difference in a laboratory value of 27.1 as compared to 7.1. This is the kind of human and mechanical error that is being made daily in terms of transcription of data.
For this reason alone, it becomes very clear that the MT today must know more about lab data, and the flawless transcription of it, than ever before.
Common Lab Tests for the MT
The average MT can edit or transcribe many reports in the course of a workday. It would not be a stretch of the imagination to estimate 20-50 reports per day, at least. It all depends on the MT's knowledge base and speed, coupled with the factor of good dictator, bad dictator.
A QA editor can review hundreds of reports—just imagine all the lab results that pass before their eyes.
Most new MTs will encounter these most common laboratory tests in their transcription from the very beginning.
- Complete Blood Count (CBC)
- Basic Metabolic Profile (BMP) or Comprehensive Metabolic Profile (CMP)
- Urinalysis (UA)
He or she needs to know the various components and normal values for all of the components of the individual tests to correctly transcribe these into written form.
However, once the MT has mastered these very basic tests, there are still many more tests that will need to be mastered. Such as:
- Coagulation profiles
- Cardiac enzymes
- Thyroid function tests
- Liver function tests
- Lipid profiles
Transcribing Coagulation Studies
Unlike some of the more complicated lab tests (like CBCs and CMPs), clotting studies have relatively few components.
This group of tests consists of the PT, PTT, and INR. These tests are used to monitor coagulation parameters and the ability of a person’s blood to clot. They are also used to test for any bleeding tendencies.
They're especially important for people who are chronically (or even temporarily) on blood thinners. It's imperative that blood clotting parameters are monitored on a regular basis to prevent excessive bleeding or hemorrhage should levels be too high.
Components of Coagulation Panels
- PT and INR: Usually written PT/INR. Used to evaluate the blood’s ability to clot. Most commonly used when patients are on anticoagulants such as Coumadin (warfarin) or drugs like Aggrenox (which contains aspirin).
- PTT or aPTT: Test used when a person has a problem with bleeding or clotting, and they are testing for a certain type of disorder
Sample Transcription of Coagulation Studies: PT 11.6, PTT 25.1, INR 1.
Analysis: This is a clipped, sentence-style dictation simply noting the patient's coagulation parameters. It would not be unusual to see several different testings for values for instance in a discharge summary.
Note that the PTT is usually about 2+ times the PT value, and the INR is usually in lower digits meaning less than 10 (or should be).
The preferred INR value for someone on an anticoagulant such as Coumadin would be between 1.5-2.5, normally. Anything above that is termed “supratherapeutic,” meaning they are overanticoagulated. In these cases, the anticoagulant drug is discontinued until the value comes back down into the preferred range to reduce the risk of bleeding or hemorrhage.
Transcribing Cardiac Enzymes
Cardiac tests are called cardiac enzymes, also cardiac markers, cardiac biomarkers, point-of-care cardiac enzymes (abbreviated POC cardiac enzymes), or just plain cardiac panel.
These tests are usually run when a patient has chest pain or other symptoms associated with cardiac disease. They are usually part of what is called a "rule out MI (myocardial infarction) protocol."
Components of Cardiac Enzymes
- BNP (B-type natriuretic peptide): Not to be confused with BMP (basic metabolic profile). How to distinguish which one is dictated? A BMP would never have a numerical value associated with it but a BNP always has a numerical value associated with it. (Exception: In a sentence such as “BMP was normal” it could be construed that “BNP was normal” as well. Take all evidence into account when deciding in that case whether it is BNP or BMP). Remember though that the BNP, is a single result whereas the BMP is the name of a test that contains multiple results (7 or 8) and they are listed as sodium, potassium, etc.
- Troponin (also called troponin I, pronounced letter I as in igloo, not “one” as in Arabic 1): This test is a check to see if someone has suffered a heart attack. Note that some hospitals or labs can perform something called a troponin T.
- CK (creatine kinase): Sometimes seen as CPK. This is an indicator of heart muscle damage if elevated (although overexercise for instance can also elevate CK levels and give a similar result). The CK total is an indicator of muscle damage, whether to the heart or other muscles in the body
- CK-MB or CKMB: This is the muscle bundle portion of the total CK test and indicates whether or not the injury is to the heart muscle or other muscles
- Myoglobin: Less often ordered. If ordered, usually ordered with troponin to check for heart attack.
Sample Transcription of Cardiac Enzymes: 3 Methods
- Troponin less than 0.4, CK-MB 2.9.
- CPK 325, CK-MB 4.7, troponin less than 0.04.
- CK was 111. MB fraction was less than 0.5. Troponin was less than 0.04.
Sometimes the sentences will be dictated in a clipped, short style with no verbs; and other times it will be dictated with conjunctions and verbs. The sentences should be punctuated as above dependent upon how they are dictated.
Note also that oftentimes cardiac enzymes are ordered in sets of 3, and they are trended to see if they rise or remain the same. A consistent rise in the enzymes usually indicates damage to the heart, and further studies are usually ordered.
About the Troponin Test
Transcribing Thyroid Function Tests
Thyroid function tests (also called TFTs) are part of endocrinological evaluations that can be done for many reasons.
It seems that testing of the thyroid is on the upswing these days, as more and more physicians are noticing a correlation between certain diseases and conditions with high and low thyroid levels.
Components of TFTs
- TSH: Thyroid stimulating hormone. Test for determining hypothyroidism or hyperthyroidism and then used for monitoring of levels when treating with thyroid medication.
- T3: Test used to diagnose hyperthyroidism and then used to monitor the condition if detected.
- T4: A total T4 and free T4 are two separate tests. They are used to evaluate thyroid function. The total T4 test has been used for many years to help diagnose hyperthyroidism and hypothyroidism. It has its uses, but unfortunately is affected by the amount of protein stored in the blood to bind to the hormone, making it possibly inaccurate.
A free T4 test is a newer version test that is not affected by protein levels so is a better test to perform for diagnostic accuracy
Sample Transcription of TFTs: Free T4 was 0.8. TSH was 1.2, which was normal.
Analysis: Many times thyroid functions are dictated only if the components are of note. Otherwise they might not be mentioned.
Transcribing Liver Function Tests
Liver function tests are ordered for many diagnostic reasons. If, for instance, a patient presents with abdominal pain, liver function tests can be done routinely to rule out gallbladder disease or pancreatitis. Some tests are often included as well on a Comprehensive Metabolic Panel (CMP).
Bilirubin testing is also done on newborns routinely to test for elevation in the levels. If elevated levels are found, therapy is initiated either before discharge home or at discharge.
Components of Liver Function Tests
- ALP (alkaline phosphatase or alk phos): This can be part of a Comprehensive Metabolic Profile, or with a group of other tests called a liver panel. This can help diagnose liver or even bone disorders.
- ALT (SGPT): As with the ALP, this test can be ordered with other tests to evaluate symptoms of liver disease. Some common symptoms would be jaundiced skin or eyes, darkening of urine, nausea, vomiting, swelling of the abdomen, unexplained weight gain, and pain in the abdomen
- AST (SGOT): This test is used in combination with other liver tests such as ALP and ALT to determine what kind of liver disease is present.
- Bilirubin (total, direct and indirect): If bilirubin is elevated, the skin becomes jaundiced—infants with hyperbilirubinemia are put under bili lights to reduce jaundice. If there is an overabundance of bilirubin, that means that too many red cells are being destroyed, or that the liver is not washing bilirubin from the blood
- Ammonia: This test is used to investigate for mental status changes or loss of consciousness. It's a test used for liver function because liver encephalopathy (mental status changes caused by poor hepatic function) can be due to elevated ammonia levels from toxins in the blood and brain. It's not necessarily a test of accuracy but more one of proving the reason for changes in mental function. If there is an elevated ammonia level, that's probably going to explain the altered mental status
- Amylase: The amylase level is used for determining pancreatitis. If it falls after a few days or so, this is usually a clear indicator of pancreatic disease.
- Lipase: This test is usually ordered with amylase to diagnose pancreatic conditions and usually based on symptoms like loss of appetite, increased or severe pain in the abdomen, fever, or nausea and vomiting
Sample Transcription of LFTs: Liver function tests on admission revealed total bilirubin 1.2, direct bilirubin 0.5, AST 50, ALT 35. Alkaline phosphatase was 86, amylase 94 and lipase 69.
Analysis: Again, this diagnostic data is transcribed as dictated paying close attention to verbs if dictated, leaving clipped sentences as dictated, and using conjunctions such as "and" when dictated.
Note: You will also hear T-bili and D-bili dictated quite commonly as an abbreviated form for total bilirubin and direct bilirubin. Preference of a facility will determine whether to expand it or leave in its short form.
Transcribing Lipid Profiles
Lipid profiles are run most often routinely in doctors' offices. However, they are also commonly run on inpatients who present for many different conditions, though primarily for cardiac-related complaints.
Cholesterol testing is also done for prevention of stroke and peripheral vascular disease (circulation problems).
Components of Lipid Tests
- Total cholesterol: This measures just that; the total amount of cholesterol in the body.
- HDL: High density lipoprotein—this is the good cholesterol measure.
- Triglycerides: Another fatty substance/indicator tested for.
- LDL: Calculated low density lipoprotein—this is the bad cholesterol figure.
Sample Transcription of Lipid Panel: Before discharge, lipid panel revealed triglycerides 124, cholesterol 104, HDL 25, and LDL 154.
Analysis: Cholesterol in this example signifies total cholesterol. Of note, oftentimes a liver panel will also be run with the lipid profile in order to check current levels, or to establish baseline values, should the patient need to be placed on anticholesterol medications; for example, for cardiac reasons discovered while hospitalized.
Diagnostic Data in Transcription
It goes without saying that medical transcription is a detail-oriented profession in all aspects. However, it cannot be emphasized strongly enough the importance and the critical nature of accurate transcription when it comes to lab and diagnostic data.
There are usually copies of lab data available in the chart or on available computers, but when medical professionals are looking for information, they most often turn to reports found on the chart. That's where accuracy really pays off.
The adage "if in doubt, leave it out" applies here. If there is any question about the correctness of a lab value, always flag it by putting _____ (5 underscores) before the value and calling it to someone's attention.
It would be impossible to cover the myriad of laboratory and diagnostic procedures here, but these are some of the more common profiles the new (and seasoned) MT will encounter on a day-to-day basis.
It's also important for the transcriptionist to know normal levels for all tests. Websites like labtestsonline.org are great sources for terminology and looking up normal values.
Here's an example of a common paragraph of lab data found on a consultation, history, and physical or a discharge summary. It shows just some of the many tests requiring accurate documentation. It also illustrates the way that they are put together in paragraph form to be read by anyone reviewing the chart. They are all together but separated out by sentences with like tests. (CBC information is all together, liver function test data is all together, etc.)
LABORATORY AND DIAGNOSTIC DATA: Hemoglobin 10.6, hematocrit 31.2, white blood cell count 10,600, and platelet count 384,000. UA showed no protein, no blood, and no glucose. Sodium 143, potassium 3.3, chloride 104, CO2 of 26, BUN 9, creatinine 1.2, glucose 106, protein 6.1, albumin 2.8, calcium 8.3. Bilirubin 0.4, AST 16, ALT 37, alkaline phosphatase 87. Amylase 97, lipase 546, repeat lipase 493. Magnesium 1.4, iron 24, TIBC 282. C-reactive protein 16. CEA 2.2. RPR negative. Rheumatoid factor negative. ANA negative. Blood gas showed a pH of 7.35, pCO2 of 34, pO2 of 80, and bicarbonate of 19. Urine culture was negative.
One of the hardest areas in medical transcription is laboratory data notation. However, with some research and study of components of the different tests, it's possible to easily become an expert on lab work transcription.
Questions & Answers
What does "high BUN" mean?
"High BUN" can be an indicator that there is something wrong with kidney function, especially if the creatinine is also elevated.
What is the medical error to a 2cms nodule when noted in the left lower lung?
That would be 2 formatting errors actually. We note as 2 cm (so not joined) and we also only note as cm always - Book of Style 12.1.5 - even if a plural (centimeters is noted as cm).