The Medical Term in a Malpractice Case
You are reporting a medical malpractice trial. A neurosurgeon testifies about a patient who developed a postoperative hematoma. The surgeon says: 'The patient developed a subdural hematoma, which required an emergency craniotomy. We evacuated the hematoma and placed a subdural drain. The patient also had a history of hypertension and was on anticoagulant therapy, which we reversed with fresh frozen plasma and vitamin K.' Later, the surgeon mentions 'the patient had a Glasgow Coma Scale of 7 upon arrival at the ER.' You are unfamiliar with 'Glasgow Coma Scale' and 'craniotomy.' You must transcribe accurately. The trial is being recorded by a backup audio system, but you are the official reporter.
1. How should you handle the unfamiliar medical terms during the proceedings?
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As the court reporter, you must transcribe accurately. If you are unfamiliar with a term, you should not guess. You can use a phonetic spelling or a placeholder (e.g., 'craniotomy' if you can spell it, or '[?]' if not) and then verify after the proceeding using a medical dictionary or by consulting the audio recording. Since there is a backup audio system, you can note the time stamp and revisit the segment. It is acceptable to interrupt briefly to ask for spelling if the term is critical and you cannot verify later, but in a trial, interruptions should be minimized. The best practice is to note the term phonetically and verify later, then correct the transcript before it is certified. You should also familiarize yourself with common medical terms in the case beforehand if possible.
2. What is the correct spelling of 'Glasgow Coma Scale' and what does it measure? How would you ensure accuracy in the transcript?
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The correct spelling is 'Glasgow Coma Scale' (often abbreviated GCS). It is a neurological scale used to assess a patient's level of consciousness. It measures eye opening, verbal response, and motor response, with scores ranging from 3 to 15. To ensure accuracy, you should verify the spelling from a reliable medical source after the proceeding. In the transcript, you would write 'Glasgow Coma Scale' and possibly include the abbreviation in parentheses if it was used. Since you are unfamiliar, you should not rely on memory; you should double-check. If the audio is unclear, use the backup recording. Accuracy is paramount because medical terms can be crucial evidence.