How To Transcribe Urinalysis Lab Results
Transcribing Lab Results Correctly
The job of the medical transcriptionist involves knowing many aspects of medicine. Part of the MT's daily routine involves analyzing correct anatomy, knowing a lot about physiology as well as being able to hear and properly identify things like suture materials or new surgical procedures.
But perhaps one of the hardest thing for the transcriptionist in the course of his or her daily duties is knowing the correct way to document lab results. From the very beginning of an MT's career, a complete understanding of laboratory transcription including correct grammar and punctuation is critical.
The most important reason for this is that a typo involving the notation of laboratory values is a critical patient safety error. While some typos can be easily caught by a trained professional reading or reviewing the record, a medical record, much like accounting, has no margin for error.
In the transcription business itself, lab errors are on the rise. This is in part due to the increasing use of voice recognition which has a great propensity for errors. That makes it twice as important for the editing MT or the transcribing MT to know what correct values are and what terminology is appropriate and more importantly, what isn't.
Urinalysis as a Screening Procedure
A urinalysis (called a UA often in dictation) is usually performed as a part of a screening battery of tests.
It can be used as a diagnostic tool as in the case of looking for substances in a patient's body such as detection of certain drugs like barbiturates or opiates.
It can also serve as a quick detector when looking for renal or metabolic disorders such as urinary tract infections or diabetes.
It's a test that can be run quickly and the results viewed almost immediately rather than waiting for blood test results.
Components of the Urinalysis Test
In order to understand punctuation and grammar in transcribing the lab procedure of a urinalysis, we have to know the components that make up this test.
Once we become familiar with the things being checked, it's easier to understand how the different components will appear in a report and how they should be typed correctly.
-Parts of the urinalysis
- appearance--this is noted sometimes but usually only when the appearance is abnormal such as cloudy, turbid, pale yellow, red or green (medications can change the color)
- specific gravity--this is an indicator of the concentration of the urine and while there are no abnormal values, it lets the provider know the urinary concentration which may be an indicator of kidney disease or other medical conditions
- pH--again there are no abnormal values for this component but the pH tells whether there is an acid or alkaline chemistry going on in the body
- protein--urinary protein is usually not detected in urine--if it is, it's called proteinuria and can be an indicator of kidney disease or diabetes
- glucose--sugar/glucose is not supposed to be present in the urine and if it is, can indicate diabetes. However, medications, pregnancy, renal failure, diseases of the liver and hormonal problems can cause glucose to be present in the urine
- ketones--also not usually present in urine, ketones are an after-effect of fat metabolism and can indicate diabetes or malnutrition--though they can occur in the urine from over-exercising, exposure to low temperatures, frequent vomiting with loss of carbohydrates and other conditions
- hemoglobin--it's not abnormal to have some red blood cells in urine though an increase in the number of red cells indicates things like kidney disease, urinary tract problems or infections, trauma perhaps to a kidney--though strenuous exercise and smoking may also cause increased red blood cells in the urine
- leukocyte esterase--this is an enzyme present in white blood cells and like red cells, some white cells are usually present in urine--however, if increased numbers of white cells are present, this could indicate an infection in the urinary tract or kidneys
- nitrite--this is a component that generally identifies presence of a urinary tract infection though someone can still have an infection with a test negative for nitrites.
NOTE: This is a common stumbling block for MTs--even though nitrites are converted from nitrates in the system, you would never find nitrates on a urinalysis--it is always nitrites
- bilirubin--when bilirubin is present in urine, it is an indicator of liver disease and can be present in the urine before a patient ever has symptoms--even before jaundice occurs
- urobilinogen--while this is usually present at low levels in urine, if detected at increased levels, this signifies a hemolysis of some kind in the body or a liver abnormality like hepatitis or cirrhosis. If the urobilinogen is abnormally low, this would indicate possibly a biliary or liver duct obstruction.
Things to Remember When Transcribing Urinalysis Results
Unlike other laboratory results, the urinalysis or UA is a unique test with unique verbiage and ways of documenting information.
- The specific gravity is most often always dictated as "10/10" or "10/25." MT's mistakenly type the spec grav that way or type in "10-10" or "10-25."
It is in fact typed as 1.010 or 1.025--always--without fail--no matter how it's dictated.
- The term "too numerous to count" is often used when describing white blood cells or red blood cells in the urine specimen--meaning there are just too many to count.
- The term "high-power field" is often mistakenly typed in "high-powered field."
- Leukocyte esterase is almost always dictated with the term nitrite, however, oftentimes will now be dictated as "LE" or "leuk est" or some other variant. Most institutions prefer that you expand that to leukocyte esterase but that is a preference needing clarification from institution to institution.
You will also hear the following dictated with regards to urinalysis:
- epithelial cells
- bacteria--usually expressed as something like 2+ or 4+
- occult blood
- proteins greater than
Dictation for Urinalysis Test Results
Let's examine a couple of sentences for transcription of urinalysis results.
Example: The UA on admission demonstrated 3+ bacteria, 1+ blood, proteins greater than 300, positive nitrites, 2+ leukocyte esterase and a specific gravity of 1.025. There were too numerous to count wbc's, 0-5 epithelial cells, a few squamous epithelial cells and moderate bacteria. There were, however, no casts and no urobilinogen.
Analysis: While the above urinalysis is a pretty big one in terms of what is usually dictated, it points out the many different things that were noted in this urine specimen.
Note that "wbc's" is usually preferred when transcribing urine results rather than WBCs.
Example: Urinalysis on admission was cloudy in appearance and was remarkable for the presence of mucus. On later clean catch specimen, it was notable for pH 6.5, specific gravity 1.025, 4+ blood with 100-200 red blood cells per high-power field. Bacteria were not seen on microscopic. However, it will be sent for culture and sensitivity.
Analysis: This would be another example of a more detailed UA that may be infected and needs culturing.
Example: A followup UA done in the office still revealed large occult blood, positive nitrites, moderate leukocyte esterase, 200-300 wbc's per high-power field, 10-15 red blood cells and 4+ bacteria. The pH on the specimen was 6 and the specific gravity 1.010. There were no epithelial cells or casts present in the urine.
Analysis: Again, this is an example of a urinalysis employing many transcription terms. It too would most likely be subumitted for culture and sensitivity.
NOTE: A urine culture and sensitivity is usually ordered on a suspectedly infected urinalysis specimen to see if a certain kind of bacteria grows and what it is susceptible to. Then it is treated with the appropriate antibiotic for the appropriate course of time. The urine is usually retested for test of cure.
Many MT's mistakenly hear "CNS" when the term "C&S" is dictated--remember that "CNS" stands for "central nervous system" whereas "C&S" stands for "culture and sensitivity"--two quite different things though they can sound alike.
Accurate Medical Transcription of Lab Results
There are many different lab tests that a medical transcriptionist has to know how to document in the course of their daily work routine.
Some tests have many components such as the CBC (Complete Blood Count) or the BMP (Basic Metabolic Profile) or CMP (Comprehensive Metabolic Profile).
It's vital that today's transcriptionist understands the different components that make up each of these tests, and more importantly what's normal and what is not--in terms of terminology and in terms of values associated with parts of each test.
Understanding all these different lab tests make any MT more marketable but more importantly, transcribing this vital information correctly will lead to the avoidance of critical patient safety errors. That is the ultimate goal of medical transcription--accurate documentation in medical records.
For explanations of lab test results and more info on various testing procedures, check out labtestsonline.org.