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How To Transcribe A Complete Blood Count
Medical Transcription Grammar
Laboratory data can be a stumbling block for many medical transcriptionists. The MT, whether new or seasoned needs to know these important things:
- What the tests are for, i.e. CBC is a blood test for anemia or infection though is used to diagnose many other conditions
- What the normal values are (or where to reference normal values)
Just as importantly as knowing why certain tests are run, a transcriptionist must also know how to punctuate laboratory data correctly within medical reports. While some people argue that grammar and punctuation are not critical to medicine, they in fact can be.
Diagnostic data errors constitute some of the most critical patient safety errors today. Laboratory and diagnostic data transcription is a breeding ground for these life-threatening errors and with the advent of voice recognition, these errors are on the rise.
It’s easy to see how knowing the names of laboratory panels and tests would be vital, but it's also extremely important that these tests be documented correctly on patient medical records.
Let's look at perhaps the most common diagnostic blood test a transcriptionist will encounter every day - the CBC.
What are the components of the complete blood count and how should they be transcribed to ensure correct documentation on a patient chart?
Punctuation and Sentence Structure for MT
Before beginning the actual transcription examples of how to punctuate laboratory data, it’s important to note that much of transcription revolves around sentence structure.
When punctuating anything in medical transcription, ask yourself these questions:
- Is the sentence complete? Is there a subject and a verb?
- Is the sentence a clipped sentence such as, “Blood pressure 120/82, pulse 92, respirations 18.”
- If there are no verbs and just clipped sentences, it's okay to join them by commas, as long as they are "like" entities.
- Does the sentence have a preposition or a conjunction, such as “with” or “and?” If it does, then you can (and should) join sentences as dictated.
- Add a period or a semicolon to separate sentence parts if you're not sure if the complete short sentence is tacked on to clipped sentences.
- Be aware of the rules for joining clipped sentences to complete sentences (even if super short). Don’t tack a complete sentence on to the end of a clipped sentence.
- Keep like items together – samples of this below.
To understand the punctuation of laboratory data, the MT first has to know what each lab test (or its acronym) is for, then the components or items found on that specific test. Lastly, the MT has to have a basic understanding of normal values to be able to flag for discrepancies.
How To Transcribe Laboratory Data – CBC
CBC is the acronym for "complete blood count." See the above image for the components as they would be listed on a real CBC test result.
There are several reasons a physician or provider orders a CBC but usually it involves checking for anemia or checking the immune system for something such as an infection or immune disorder such as leukemia.
-Components of the CBC
- (remember that CBC is the name of the test and will not ever have a number associated with it – it just stands for Complete Blood Count)
- RBC (red blood count)
- WBC (white blood count or white blood cell count )
- platelets or platelet count
The differential is a subtest of the WBC and tells what kinds of white cells there are. It can consist of these types of white cells and each will have a number or percent assigned:
- neutrophils – also called polys, segs, bands
- eosinophils – called eos
- basophils – called basos
- lymphocytes – called lymphs
Red cell indices are subdivisions of the red blood count and each has a numeric value.
- MCV – mean corpuscular volume
- MCH – mean corpuscular hemoglobin
- MCHC – mean corpuscular hemoglobin concentration
RDW – red cell distribution width
Transcription of Basic Blood Work
All of these related tests come under the heading of the CBC. When transcribing this set of laboratory values, you look for the following criteria on which to base your punctuation:
- What are the components of the CBC that are dictated? (only some are often dictated)
- If the differential is dictated, it is part of the white cell count and must be handled appropriately
- The red cell indices should be punctuated correctly as those are part of the red cell count (if dictated)
- Check sentence structure – clipped or short and complete; punctuate accordingly.
EXAMPLE: On admission, the CBC showed white blood cells 8.4, hemoglobin 14.4, hematocrit 44.2, platelet count of 245. Segs 20, lymphs 70.
Analysis: The differential of segs and lymphs are transcribed as a separate clipped sentence because these components are part of the differential WBC information but the information follows the platelet count. The differential is related to the CBC but it is NOT related to the platelet count so must stand alone in its own sentence. If "Segs 20, lymphs 70," were to be tacked on after platelet count information, it would imply that the differential information is part of the platelet count information (which would be incorrect).
Word about platelet counts – some institutions will ask that you type it as dictated, so “245” would be appropriate if that was dictated. Or “245,000” would be appropriate if that were dictated. But some facilities will also ask that you routinely expand “245” for the platelet count to “245,000” regardless of how it was dictated.
This is a preference that you will be made aware of by each facility or transcription service. It is not a conflict in transcription but rather an example of preference by one entity or another. Many curriculums, however, require that you expand the platelet count so that you will know that this is sometimes a requirement for transcribing this part of blood work.
EXAMPLE: CBC shows hemoglobin 14.1, hematocrit 44.8, WBC 10.0 with 24 segs, 70 lymphs, 3 monos and 2 eos. Platelet count 248.
Analysis: Here, the verb “shows” was clearly dictated so you would type as dictated. The preposition “with” was dictated so you would not separate out the differential elements (segs, lymphs, monos and eos) from the sentence. They also nicely follow the WBC itself. However, the platelets, while associated to the CBC, are NOT associated to the white cell count differential so you would make a small clipped sentence, separating platelets from the white cell differential information.
Grammar and Punctuation in Medical Transcription
In the day and age of speech recognition, many argue that punctuation is not that important.
For the clinician reading the patient’s medical record, however, it is crucial that it's concise and appropriately punctuated. This helps to avoid the possibility of a safety error for a patient that could result simply because lab values were written/typed incorrectly.
Let’s look at a sample of a real paragraph a medical transcriptionist would encounter. This paragraph would be in an admission history and physical or in a discharge summary describing the sum of diagnostic data completed.
EXAMPLE: LABORATORY DATA: The patient had a normal EKG on admission. CBC: Hemoglobin 14.5, hematocrit 45.2 and MCV 91.2. White blood count 7.6 with 2 bands, 68 lymphs; 228,000 platelets. Sodium was 140, potassium 3.4, chloride 102, CO2 of 27, BUN 7, creatinine 0.8, glucose 110 with a calcium of 8.4. Albumin was 3.2, total protein 7.4, alkaline phosphatase (dictated alk phos) 114, ALT 27, AST 13, and total bilirubin 0.2.
Analysis: The CBC information was separated appropriately in the first sentence and since there was a conjunction "and," it was permissible to add the MCV information. The next sentence separates out the white cell count and its differential. It separates platelet information from that by a semicolon. A new sentence was created starting with "albumin" because the verb "was" was dictated after albumin.
Keep in mind these two additional factors:
- All lab values have a “normal” range. It's up to the MT to look up the normal ranges and if there is not a lab abnormality or condition mentioned in the rest of the report to support that abnormal lab, it should ALWAYS be flagged by putting _____ in front of the value questioned to call attention to it.
EXAMPLE: The patient's diagnoses mention severe anemia. The CBC is dictated to reflect a value of hemoglobin 7 (which is far below levels considered normal). However, because the patient has severe anemia, this would be accurate transcription of the lab value.
- Not all components of a lab test have to be dictated and many times are not. For ease of reading, many dictators only mention lab values of note. In these instances, you end up with a CBC without 2 or 3 of the components dictated. The assumption is that they were not noteworthy enough to comment on.
Transcribing Complete Blood Counts
Since the CBC is the most common blood test ordered on patients, both inpatient and outpatient, an MT should be familiar with all components of the test and how they should be typed accurately.
Practice will enhance the medical transcriptionist's skill level at recognizing discrepancies and will also reinforce best practices when it comes to transcribing medical diagnostic data.
All parts of medical transcription are equally important as they contain critical information regarding a specific patient. However, learning to transcribe laboratory tests correctly is one of the best ways to reduce critical patient safety errors and improve patient care.
For more information on this lab tests and other diagnostic procedures, check out labtestsonline.org.