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.

Part 1 Multiple Choice (Cognitive)

Know English language (15%)

• Know basic grammar rules.
• Know punctuation rules.
• Know English usage.
• Know the spelling of English words.

Know medical transcription style (5%)

• Know the basic medical report types and the elements of each.
• Know the appropriate placement of dictated information in a medical report.

Know medical language (25%)

• Know the meaning and spelling of prefixes, suffixes, combining forms, and root words.
• Know commonly misspelled medical terms.
• Know the plural forms of medical terms.
• Know the meaning and spelling of documented medical abbreviations and acronyms.
• Know the meaning and spelling of medical eponyms.
• Know the meaning and spelling of medical homonyms and synonyms.
• Know medical terminology and spelling related to anatomy/physiology.
• Know terminology and spelling related to laboratory medicine.
• Know terminology and spelling related to anatomic pathology.
• Know terminology and spelling related to imaging studies.
• Know terminology and spelling related to other diagnostic studies (e.g., EKG, EEG, EMG, etc.).
• Know medical specialty terminology and spelling.

Know anatomy and physiology (25%)

• Know the function and structure of organ systems.

Know disease processes (20%)

• Know names, signs, symptoms, diagnosis, and treatment of common diseases and conditions.

Know medicolegal issues regarding the healthcare record (10%)

• Know regulatory requirements (HIPAA, JCAHO, etc).
• Know the purpose and content of the healthcare record (e.g. continuity of patient care, etc.).
• Identify risk management issues.

Part 2 Content Outline (Practical)

Know English language. 19%

Know medical transcription style. 4%

Know medical language. 33%

Know anatomy and physiology. 26%

Know disease processes. 18%

Specialties Covered

Cardiovascular, gastroenterology, internal medicine, pulmonary medicine, neurology, psychiatry/psychology, otorhinolaryngology, dermatology, Ob-Gyn, orthopedic, urology, and ophthalmology, general surgery (basic).

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 stressed a great deal will be spelling (soundalikes, frequently misspelled English and medical words), grammar, punctuation, units of measure, medical symbols, abbreviations, lab data, imaging data, and drug indications and dosages. Also covered will be risk management issues, inconsistencies, and American slang and colloquialisms.

Report Types

H&Ps, Consultations, Operation/Procedure Notes, Discharge Summaries, Radiology reports, Pathology reports, clinic notes, letters, and progress reports. Format styles and structure, however, are not covered.