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How To Transcribe Urinalysis Lab Results

Updated on August 11, 2012

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.

Medical transcriptionists routinely transcribe urinalysis results
Medical transcriptionists routinely transcribe urinalysis results | Source

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.

Remember these!

  • 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:

  • casts
  • 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.


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    • profile image

      Abdur Rahman 

      5 months ago

      Wonderful

    • akirchner profile imageAUTHOR

      Audrey Kirchner 

      6 years ago from Washington

      Helen - why thank you~ Actually I do about 20 different hospitals (or more) in a day - so I have to keep all of their individual requests and preferences in my head (and on pdf files~~~) - it really is not an easy job but thankfully one I've been doing for so long it kind of is easier for me than most I guess. Thanks so much for your stopping by~

    • Seeker7 profile image

      Helen Murphy Howell 

      6 years ago from Fife, Scotland

      Another superb hub Audrey and again with so many interesting facts. Reading through your hub I was just wondering how difficult would it be for an MT who has become very familiar with there work at one institution and then moves to another to do similar work? As you mentioned in your hub, some institutions have different abreviations for critical data.

      But again your hub just highlights the essential work done by so many highly skilled people behind the scenes in healthcare and never really get acknowledged for it - so I'll do it now, I salute all MT's, I think they do a fanatastic job under, what must be, high pressure and stress.

    • akirchner profile imageAUTHOR

      Audrey Kirchner 

      6 years ago from Washington

      Prazyes - not yet but you have to wonder why SO MANY PEOPLE are on dialysis today? There are clinics virtually everywhere. Having had a kidney problem myself, this is very concerning to me! Thanks for bringing that up - at the moment I'm stuck on this part of the "program" but food for thought in the future~

    • Prayzes profile image

      Prayzes 

      6 years ago

      This is an interesting article. Have you written anything on dialysis? Do you have thoughts on what is causing the exponential development of dialysis clinics?

    • akirchner profile imageAUTHOR

      Audrey Kirchner 

      6 years ago from Washington

      Well, Lela - it's a tough one but now that I'm into old lady synchronized swimming (trying for the senior olympics)....I feel like I can safely probably give up the belly dancing though Bob is going to be very disappointed...I haven't told him yet but if he likes my Esther Williams moves, I may have a prayer still~

    • Austinstar profile image

      Lela 

      6 years ago from Somewhere near the center of Texas

      Oh no! And give up belly dancing?

    • akirchner profile imageAUTHOR

      Audrey Kirchner 

      6 years ago from Washington

      Thanks, Lela~ Good point - I should include websites to check out the lab reference ranges...back to the drawing board and must add those in all my 'brainiac' hubs....teaching on-line is proving to be a challenging profession but I do like it~ I had someone else tell me I should become a pharm tech although I think at this stage in my life, I'd rather be a FARM tech~ ha ha

    • Austinstar profile image

      Lela 

      6 years ago from Somewhere near the center of Texas

      There is a very good web site that describes all lab tests. If you ever need to interpret lab tests, you might want to use it - LabTestsOnline.org

      I had thought to write about all of the tests myself, but I would only be copying this site.

      Enjoy!

      Brain surgeon is out, Pharmacist is in!

    • akirchner profile imageAUTHOR

      Audrey Kirchner 

      6 years ago from Washington

      Hi Virginia - good point~ Yes I probably should do one for people who are not in the real business as it is confusing even for us that ARE in it! And ouch....those are awful. Hope you don't have that happen again...I had a bout with severe headaches about 2 years ago and hypertension which I've never had. It turned out I have renal artery stenosis and had to have both angioplastied open - that was weird and not fun at ALL but I now have a very healthy respect (and worry) about my kidney functions~!!! Hoping and praying that the arteries just stay open so I never have to go through that again....ever! It wasn't the worst thing I suppose but it certainly was not pleasant. Take care...I should do one on kidney stone diets too as I have a friend who gets them chronically! (Or you should....)

    • VirginiaLynne profile image

      Virginia Kearney 

      6 years ago from United States

      This was so much helpful information and so very clearly presented. I just had a kidney stone and was looking at my own lab results and wasn't able to process the information well. I hope you will write a Hub on how to read your own lab results. I would love to be able to understand what those results mean.

    • akirchner profile imageAUTHOR

      Audrey Kirchner 

      6 years ago from Washington

      BJ - ah yes...that is a consideration except that I faint at the sight of blood...especially my own but others' as well. That probably would get a little messy when I was poking about in someone's brain. There is probably a very good reason I'm a behind the scenes kinda gal~ Thanks for the visit, BJ...as always.

    • drbj profile image

      drbj and sherry 

      6 years ago from south Florida

      You need so much medical information to process and remember in the complicated field of MT professionals, Audrey, that in your next life you may want to choose to be a brain surgeon. So much easier, m'dear!

    • akirchner profile imageAUTHOR

      Audrey Kirchner 

      6 years ago from Washington

      Indeed~ It is a very complicated medical field but if you think of the amount of information an MT must process, it isn't surprising.

    • Laura in Denver profile image

      Laura Deibel 

      6 years ago from Aurora

      Interesting how complicated this is.

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