How to Create Medical Transcription Templates & Forms in Microsoft
As a medical transcriber, you listen to dictated recordings made by doctors and other healthcare professionals and transcribe them into reports or other administrative material. Documents typically include medical histories, physical-exam reports and referral letters. So that you can quickly return transcribed documents to the people who dictated them for review and approval, make use of tools, such as typing automation, templates and forms. For example, create and use a template for "normal" examinations that meets the criteria of your client, to maximize your productivity.
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Instructions
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Open a Microsoft Word document that contains the information you want. Base your template on this document. For example, a normal exam can contain this content:
PHYSICAL EXAMINATION
GENERAL: The patient is awake and alert.
HEAD: Pupils are equal, round and reactive to light.
EARS: The ear canals are patent without edema, exudate or drainage.
NOSE: Without deformity, bleeding or discharge.
ORAL CAVITY: No swelling or abnormality to the lip or teeth.
NECK: No signs of abnormality.
CHEST: Symmetrical with equal breath sounds.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm.
ABDOMEN: Soft, nontender and nondistended.
EXTREMITIES: No deformity or signs of trauma.
SKIN: No rashes.
NEUROLOGIC: Cranial nerves II through XII are grossly intact.
PSYCHIATRIC: Mood and affect are appropriate.
Approved:
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Add a menu. Click the "Microsoft Office" button and then click the "Word Options" button. Click the "Popular" option and then select the "Show Developer tab in the Ribbon" check box. Click the "OK" button.
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Click the "Developer" tab. Click the "Drop-Down List" option. Click the "Properties" option. For example, enter "Approval Menu:" in the "Title" field. Click the "Add..." button and enter "Yes" as the "Display Name" and click the "OK" button. Click the "Add..." button and enter "No" as the "Display Name" and click the "OK" button. Click the "OK" button to complete your menu associated with the "Approved" label for the document in the first step.
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Click the "Developer" tab. In the "Protect" group, click the "Protect Document" option and then click the "Restrict Formatting and Editing" option. Under "Editing restrictions," click the "Allow only this type of editing in the document" check box. Select the "Filling in Forms" option. Under the "Start enforcement" area, click the "Yes, Start Enforcing Protection." Click the "OK" button. These actions create your form.
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Click the "Microsoft Office" button and click the "Save As" option to make this document a template. In the "Save as type" box, click the "Word Template" option. A template contains the structure and layout that establishes consistency and accuracy between documents with similar content. Close your document. Now you can use this template and form in your work to save you time and increase your accuracy.
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References
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