Exam items are based on the content outline below in the percentages noted. Not all items may be covered on the exam, and additional areas may be added as the practice of medicine and medical transcription changes over time.

Medical Transcription-related Knowledge (approximately 50% of entire exam)

   Medical language (approximately 40% of the knowledge section of the exam)

• Meaning and spelling of prefixes, suffixes, combining forms, and root words.
• Plural forms of medical terms.
• Meaning and spelling of documented medical abbreviations, acronyms, eponyms, homonyms, and synonyms.
• Terminology and spelling related to anatomy/physiology, clinical medicine, pharmacology, laboratory medicine, pathology, imaging studies, and other diagnostic studies (e.g., EKG, EEG, EMG, etc.).
• Specialty terminology and spelling (approximately 80% of the specialty terminology questions will come from: allergy and immunology, basic lab tests and values, cardiology, emergency medicine, endocrinology, family medicine, gastroenterology, general surgery, hematology/oncology, imaging studies, infectious disease, neurology, obstetrics/gynecology, ophthalmology, orthopedics, otorhinolaryngology, pediatrics, physical medicine and rehabilitation, podiatry, psychiatry/psychology, pulmonary medicine, urology.
• Specialty terminology and spelling (approximately 20% of the specialty terminology questions will come from: alternative medicine, cardiac surgery, chiropractic, dentistry and oral surgery, dermatology, genetics, geriatrics, neurosurgery, nutrition/dietetics, pain management, plastic surgery, rheumatology, thoracic surgery, vascular medicine, vascular surgery.

   Anatomy and physiology (22%)

• Structure and function of cells and tissues.
• Structure and function of organs and systems.

   Disease processes (15%)

• Names of common diseases and conditions.
• Signs and symptoms of common diseases and conditions.
• Diagnosis and treatment of common diseases and conditions.

   English language (12%)

• Basic grammar rules.
• Punctuation rules.
• English usage.
• The spelling of English words.

   The healthcare record and important medicolegal issues (11%)

• Basic medical report types and the elements of each.
• Regulatory requirements (HIPAA, JCAHO, etc).
• Principles and processes for keeping audit trails.
• The purpose and content of the healthcare document.
• Identify risk management issues.

Transcription Performance (approximately 50% of entire exam)

• Approximately 55% of the items in the performance section of the exam
  will be transcription, 30% editing, and 15% proofreading against the audio.

   Report Types

• The items in the performance section will come primarily from operative reports, procedure notes, consultation reports, discharge summaries, and history & physicals, and secondarily from imaging studies and pathology reports. A small percentage will come from clinic notes, letters, and progress notes.

   Specialty Areas

• The material in the performance section comes from a cross section of medical specialties divided approximately equally among four groups:
• Group A: cardiology, endocrinology, gastroenterology, geriatrics, hematology/oncology, hepatology, pulmonary medicine, rheumatology
• Group B: allergy and immunology, alternative medicine, chiropractic, dermatology, emergency medicine, family medicine, genetics, infectious disease, neurology, nutrition/dietetics, otorhinolaryngology, pain management, pediatrics, physical medicine and rehabilitation, podiatry, psychiatry/psychology, vascular,
• Group C: general surgery.


• Group D: cardiac surgery, dentistry and oral surgery, neurosurgery, obstetrics/gynecology, ophthalmology, orthopedics, plastic surgery, thoracic surgery, urology, vascular surgery.

   Interpretability

• Approximately 90% of the dictation in the performance section will be by clear dictators on clear recordings, while the remainder will be by dictators who may be difficult to understand or from recordings that are compromised in some other way.

   Transcription Issues Covered

• Transcription issues covered will include the spelling of medical and English words and using difficult grammar or punctuation, units of measure, medical symbols and abbreviations, lab data, drug indications and dosages, imaging data, and a small percentage of inconsistencies, risk management issues, and American slang and colloquialisms.