Expert Tips for Accurate Laboratory Data Transcription

Reviewed by Becky Byrns, CHDS, CHDP-S, CEHRS, MSK and Healthcare Documentation, Health and Wellness Program Manager at CareerStep.

Precise and accurate documentation is critical in healthcare and medical transcriptionists play a vital role. CareerStep’s Medical Transcription Program is designed to equip students with the skills needed to excel in this field. Transcribing laboratory data, such as the details found in a Chem 10 blood test, is a routine task for medical transcribers. They must ensure that each value is recorded accurately, as even a small error can have significant implications for patient care. With the help of Becky Byrns, CHDS, CHDP-S, CEHRS, MSK and Healthcare Documentation, Health and Wellness Program Manager at CareerStep, this post dives into the intricacies of laboratory data and explores the importance of meticulous documentation.

Importance of accurate transcription of laboratory data in medical reports

Becky Byrns emphasizes that inaccuracies, such as transposing numbers, can lead to critical errors affecting patient care.

“Simply transposing two numbers could cause an incorrect treatment to be initiated,” she says, putting into perspective how easy it is to make mistakes in this field. It is vital to accurately transcribe laboratory data to ensure the best possible patient care.

Challenges faced by medical transcriptionists

Medical transcriptionists often face significant challenges when working with laboratory data. Fast-talking physicians or those with an accent unfamiliar to the transcriber can make transcription difficult. Additionally, physicians might dictate incorrect values, which Byrns advises then need to be “flagged with a blank so the physician can verify the value.” She points out the importance of a strong knowledge base and up-to-date reference materials for transcriptionists to navigate these challenges effectively.

Staying updated with medical terminology and lab test names

Medical transcriptionists must stay current with changes in medical terminology and laboratory test names. While the core laboratory values do not frequently change, new tests do emerge as medical science advances. Byrns shares that once the common laboratory values are learned, however, they remain relatively stable, but staying informed about new developments is crucial.

A transcription conundrum

Here’s an example of why keeping up with changes is so important as a transcriptionist:

A transcriptionist needs help with a report they’re reviewing. The transcription key provided by the client showed the lab test and value “IB 4.4.” Stedman’s Pathology & Lab Medicine Words listed immune body and inclusion body as possible expansions; however, neither was compatible with the value 4.4. Although not everyone’s listening ears were in agreement, IP was the popular vote, and the wild goose chase began.

The dictator’s style was notable. He dictated every term in full in the laboratory section with the exception of BUN and the stumper term. Therefore, it could be reasonably concluded that this abbreviation represented a very common laboratory term that didn’t require an MT with superpowers to decode.

Despite the context being pretty normal for the lab section—simply other labs and their values—it proved to be useful. The surrounding labs provided valuable clues as to the type of panel that had been performed and, ultimately, led to the missing term. The lab section containing the unknown abbreviation was dictated as follows:

BUN 99, creatinine 7.0, sodium 142, potassium 5.3, chloride 102, carbon dioxide 25, glucose 114 and calcium 8.9, magnesium 3.0, (___) 4.4.

It appeared the patient had a basic metabolic panel, along with some other blood work. Calcium is part of the basic metabolic panel, but magnesium is not.

Newer MTs may not be aware of some of the changes that have impacted the medical field and thus the medical report, and this is a great example of such a change. It used to be very common to hear lab results of a chemistry panel dictated as “chem” followed by a number. Chem-7 and chem-12 were at the top of the list for popularity. Over time, these tests changed a bit and are now more commonly referred to as the basic metabolic profile (BMP) and the comprehensive metabolic profile (CMP). Further, the BMP generally includes 8 labs rather than just 7, with the additional lab being calcium. Chemistry panels weren’t limited to chem-7 or chem-12; one might have had a chem-10 or chem-14 or some other chemnumber, depending on how many labs were included. The chem-10 consisted of blood urea nitrogen, creatinine, sodium, potassium, chloride, carbon dioxide (sometimes called bicarbonate), glucose, calcium, magnesium, and phosphate! But wait—the abbreviation for phosphate (phosphorus) is P, not IP…or is it?

It is actually the inorganic phosphate that is measured when a phosphorus lab is ordered, but the vast majority of dictators—and others involved in the medical field—refer to it simply as phosphorus or P; for the most part, the inorganic part of the term has been dropped. Ultimately, it comes down to dictator preference, and this dictator decided to be the odd duck who prefers IP. While he may be an odd duck, the wild goose chase was finally over.

Helpful resources and tools

Gone are the days when medical transcriptionists needed extensive libraries of reference books. Once upon a time a medical transcriptionist may have thought of manuals like Stedman’s Pathology and Lab Medicine Words as their best friend, but today, a simple Google search can yield accurate information quickly. Byrns highlights the importance of being competent in online research, as it allows transcriptionists to verify laboratory values and terminology efficiently.

Advice for new medical transcriptionists

For those new to the field, the plethora of laboratory values can be overwhelming. Byrns advises patience and methodical learning, suggesting that printing out common laboratory values or bookmarking reliable webpages can be helpful. Over time, these values become second nature, ingrained in the transcriptionist’s memory. “It is important to be patient and take your time,” Byrns says.

Become a medical transcriptionist

Accurate transcription of laboratory data is critical in healthcare documentation, and despite the challenges, medical transcriptionists have numerous resources at their disposal. By staying updated and utilizing modern tools, they can ensure precision in their work, ultimately contributing to better patient care.

If you’re interested in becoming a medical transcriptionist, it’s important to learn some foundational medical knowledge – including HIPAA regulations and standard transcription processes. With an online medical transcription training program, you can learn the ins and outs of medical transcription from home, at your own pace.

For more information, or to enroll, reach out to our admissions team at 1.800.411.7073!