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How To Transcribe A WHOLE Blood Count
Medical Transcription Grammar


Laboratory data can be a stumbling block for most medical transcriptionists. The MT, whether new or seasoned must know these considerations:

What the tests are for, i.e. CBC is really a blood test for anemia or infection though is used to diagnose a great 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 understand how to punctuate laboratory data correctly within medical reports. Although 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 really a breeding ground for these life-threatening errors sufficient reason for 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 will be vital, but it's also extremely important that these tests be documented correctly on patient medical records.
Let' medical transcription business at perhaps the most common diagnostic blood test a transcriptionist will encounter every day - the CBC.

What are the the different parts of the entire blood count and how should they be transcribed to make sure correct documentation on a patient chart?
Punctuation and Sentence Structure for MT


Before beginning the specific 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:

May be the sentence complete? Will there be 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 become listed on them by commas, as long as they're "like" entities.
Does the sentence have a preposition or perhaps a conjunction, such as for example ?with? or ?and?? If it can, then you can (and should) join sentences as dictated.
Add a period or perhaps a semicolon to separate sentence parts if you're not sure if the entire short sentence is tacked to clipped sentences.
Be aware of the guidelines for joining clipped sentences to perform sentences (even though super short). Don?t tack a whole sentence on to the end of a clipped sentence.
Keep like items together ? samples of this below.
To comprehend the punctuation of laboratory data, the MT first has to understand what each lab test (or its acronym) is for, then your components or items found on that specific test. Lastly, the MT really needs a basic knowledge of normal values in order to flag for discrepancies.

How To Transcribe Laboratory Data ? CBC

CBC may be 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 lots of reasons your physician or provider orders a CBC but usually it involves checking for anemia or checking the immune system for something such as contamination or immune disorder such as leukemia.

-Components of the CBC

(remember that CBC is the name of the test and won't ever have a number connected with it ? it just means Complete Blood Count)
hemoglobin
hematocrit
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 types of white cells there are. It can contain these kinds of white cells and each will have lots 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 includes 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


Many of these related tests come under the heading of the CBC. When transcribing this group of laboratory values, you search for the following criteria on which to base your punctuation:

What are the the different parts of the CBC which are dictated? (only some are often dictated)
If the differential is dictated, it is area of the white cell count and should be handled appropriately
The red cell indices should be punctuated correctly as those are section 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 another clipped sentence because these components are part of the differential WBC information however the information follows the platelet count. The differential relates to the CBC but it is NOT linked to the platelet count so must standalone in its own sentence. If "Segs 20, lymphs 70," were to be tacked on after platelet count information, it would imply the differential information is section 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? will be appropriate if that was dictated. Or ?245,000? would be appropriate if that were dictated. However, many facilities may also ask that you routinely expand ?245? for the platelet count to ?245,000? it doesn't matter how it was dictated.

This is a preference you will be made aware of by each facility or transcription service. It is not a conflict in transcription but instead an example of preference by one entity or another. Many curriculums, however, require that you expand the platelet count so you will know that this is usually a requirement for transcribing this section 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 and that means you wouldn't normally 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, aren't associated to the white cell count differential and that means you would create a small clipped sentence, separating platelets from the white cell differential information.

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