Approve what? The information used is already part of the medical record and, therefore,...sm
Posted By: JLH on 2007-02-24
In Reply to: Doesn't have to be dictated...but he does - have to approve this beforehand..nm
has already been approved or authenticated or whatever one wants to call it.
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if it was in my medical record?
It would depend upon whether or not it could have a negative impact upon my medical care. If the doctor dictated something like, "The patient has diabetes" (when I don't), yeah, I would ask them to correct the record. But for something like what was stated originally ... heck no. Let it stay.
But that's me ... I don't have OCD and I'm not anal retentive about this business like others. Never have been and never will be.
I still think you need to lighten up. There's a lot more to worry about in life than something like that.
It is about CLARITY in the medical record.
It makes the medical record easier to read, which means more accurate patient care
electronic medical record nm
/
A.S. in Medical Record Technology
This included a course in Medical Transcription. Went to work in a physician's office. My job title was medical records, but the main component of the job was transcription. This led to later full-time transcription job.
Let me tell you about falsifying a medical record
I know first hand it has been done and it was done about me. I had plastic surgery (3 part type) with face lift, tummy tuck and lipo in 2002. The doctor "forgot" to do the face lift. Had paid up front and I asked for the portion of the face lift only returned. He gave me an IOU on his office station but then later would not pay me and get this --- 8 months after the surgery he dictated my report, put in the face lift like he had done it along with the other. Now most people would say well, maybe he got you and someone else confused. Not so- this same physician who was head over the plastic at the hospital called me personally at my home, not through his office, but him personally twice in a threatening like voice when I tried to take thru mediation. I worked inhouse at the time and rather than risk my job, I left it up to Karma. This actually happened to me. I went to the lady over medical records, I worked in the same department, and told her exactly what had happened and she said I could write a note to put in the front of the chart disputing it had been done. Unbelievable, huh?
Protective of the US medical record???
She employed offshore MTs...how protective could she have been? Are you kidding me?
The actual medical record contains
those things you mention. The dictated report sometimes does, not that is not often. Some facilities, however, do have the physician dictate everything imaginable and even if it is 1 out of every 10, that is still too much info to let out.
I think that is very unprofessional for a medical record. nm
x
EMR (electronic medical record) and voice
Yes, they are pushing to make medical records electronic, instead of a paper chart. That doesn't affect MTs. We still transcribe reports and instead of the reports being printed and filed in a paper chart, they are part of the electronic record and can be accessed at any computer in the hospital , for instance. The doctor can sit at the nursing station and pull up all the dictated reports, the lab, radiology reports, etc.
Voice recognition, of course, is something different. There is no one saying that VR has to be used by 2012. That's simply an alternate way of getting the dictation onto the EMR.
Big deal is legal, medical record which should be the
truth, not a made up report. Medical records are supposed to stand in court just as a sworn statement, that is all. I like the truth and that is the way I try to live my life, not a bunch of falsehoods. I guess others can live on lies if they want.
The electronic medical record has replaced MTs at my job..it's all over!
My job has been scanning all the medical records over to electronic medium and the doctors are now taking laptops in the exam room with them and typing in all the info, so basically, my job will be obselete once this transition is over. 
Our boss has been doing a comparison of the clinics who now have the electronic medical record--those docs went from dictating thousands of lines in a weekly period to less than 50!!! Of course this is a tremendous difference and it's "lights out" for us MTs. We've got about a good year before it's all done.
Have any of you been affected by this new technology?
P.S. I didn't care so much anyhow...I hate this industry and this job, so I've been looking for other employment anyhow.
i personally would not want my boss typing my medical record either
nm
ALL of the clinics I work on use SS #s as medical record numbers, and many of them cc to the
patient at their home address, which is conveniently typed at the bottom of the report. Seems pretty straight-forward to us, then why can't the govt figure this out and put a stop to it?
again, making medical record digital does not affect us.
nm
Have MTSO's or IC's all become electronic medical record suppliers as well as transcription pr
I've been an IC for over thirty years and the medical offices are now asking me if they can search for old records? What, they don't keep their own records anymore? Do all MT companies now offer searchable databases on their company servers for the physician's staff or do they install databases on the physician's computers for this sort of thing? I've been asked to provide this and I'm thinking "wow, can't the office staff open word and find the appropriate folder and file?" Is this now a standard item offered by MTSO's? What happened to medical office management software? Are transcription companies now becoming electronic medical records suppliers? If so, please let me know.....If so I've become a dinosaur!
Our medical information is public domain?
thats nuts. I dont even know how you come to that conclusion.
Ask your physician next time if his medical information is public domain and see what he says.
right? isn't there a board for personal medical information posts?
Manufacturing computers offshore is different than PRIVATE MEDICAL AND FINANCIAL INFORMATION. sm
you need to compare apples with apples not oranges.
Health information personnel, medical records, clerical..sigh...nm
s
MQ part-time benefits do NOT include medical/dental. Nm
nm
Transcription Gear would have to approve the transfer of license from
I don't even know if they allow this. You should check into that first.
Have your medical dictionary handy while taking the multiple choice part of the test.(nm)
x
The easy part is making the decision to leave, the hard part is
actually doing it. Been in your shoes and it took me a year and a half to leave after I had made the decision to do so. It was the best thing I have ever done for myself and my girls. I had family and friends and a counselor telling me what needed to be done and I knew what needed to be done but until I had the courage on my own to do it I stayed. One day, we had an argument and he spit in my face and that was the last straw for me. Even though it is something that I will NEVER forget, that day is also a day I will never forget because it is the day that I took my kids and left. I am a single mom of 2 and have been single and supporting us for 5 years now. I have been healing ever since and still am to this day. You can do this. I know that if I hadn't have left and I would have stayed one of us would be dead by now or both.
I would buy new a Dorland's Medical Dictionary, Stedmans Medical and Surgical Equipment...SM
and Tessier's The Surgical Word Book, 3rd edition. Books you could buy used I would say would be Stedman's Pathology and Lab Medicine and Cardiology/Pulmonary word book. These are all the books I use the most during my day. You could buy other speciality word books as you need them and could probably go used with those.
I wouldn't bother with buying a drug book, new editions come out every year and I just stick to the FDA website and RXList as my drug references.
Also FYI, not a book, but I use my Stedman's Electronic Medical Dictationary a lot. It's easier to open the program than it is to pick up a huge 30-pound dictionary.
Medical Transcription In The Era Of Electronic Medical Records
EMR has revolutionized the healthcare industry in recent times. Many experts felt that EMR & Voice Recognition would totally replace Medical Transcription - however; the industry soon realized that transcription has certain advantages over point & click charting and many physicians preferred to dictate notes rather than document the data at the point of care themselves.
For the record,
the solo-practices and smaller offices are outsourcing to the hospitals...
can anyone set the record for
My record is around 45. Right now i'm on a report that is up to about 23. Talk about toxic!
re-record
If re-recording to digital, pretty easy. Play either in handheld or transcriber, and use either computer or digital handheld to capture. Just need the connecting cord between two units - can get at Radio Shack.
expunging record
Just a thought -- a friend had a felony from years ago expunged from her record -- but background checks from then on noted the expungement on her record -- which raised red flags in itself.
another broken record...
me too. It absolutely befuddles me that anyone would be trying to get INTO this field, especially with all the ominous signs that are right out there for anyone to see. I think new moms with babes are just blinded by the idea of "working at home" and can't see the competition they are facing. Me, I am in nursing school... not an easy job by any means...but I'll be good at it and will find my niche quickly and will always have a job! My biggest account is making noise about getting a VR system. If I wasn't in nursing school, I would be having a panic attack instead!
How did he get his record cleared?
You mentioned that he has a "clean record." I still have this thing on from 11 years ago. Did he have to do something in particular to clean his record or did it just drop off?
We all make dumb mistakes at some time in our lives, eh? LOL
Med Record Retention
That's a very broad question. It's my understanding that the answer depends on the State and the age of the patient at the time of service. Liability required juvenile records be kept forever since it used to be a base could be brought when the injury was first noticed, and that could be well into the adult years.
You have to record to the computer
Get a program like GoldWave (I think goldwave.com). You can buy a plug that goes one end in the transcriber and the other in the computer. One end goes in the transcriber earpiece plug and the other goes in the computer microphone plug.
Then play the transcriber while using Goldwave (or whatever) to record from the microphone input. It creates a WAV file or whatever you specify.
LOL. Did you tell your doctor so he could record it? - NM
NM
That particular patient's record
is still confidential information, thus protected. Who knows, there may be contributing factors about that other patient and that is why the name was mentioned. Either way, if it was dictated to be transcribed and fits with the account specs, it is to be transcribed. I've worked for companies that did and did not allow patient and other names in their records, sometimes it just depends on what the client wants.
Public record
http://www.fbodaily.com/archive/2009/05-May/30-May-2009/FBO-01829906.htm
http://www.fbodaily.com/archive/2009/05-May/30-May-2009/FBO-01829905.htm
These 2 companies were just awarded all of VISN 7. Not sure exactly where the split is. Look on VA website for hospitals make up VISN 7.
Why don't you set the record straight Ms. AAMT?
Why are you sooooooo defensive?
Setting the record straight
You purchased an IN-155 foot pedal for compatiblility with DVI VoiceWav. (We have sold nearly 1,000 of these with zero returns.)
When you called our toll free 800 number for support we told you that the problem was not the pedal and was either the software you were using or your computer. Reluctantly, we agreed to do an exchange for you. (FYI, when your first pedal came back to us it worked absolutely perfectly and still does. In fact it is plugged into the same computer I am typing on at this moment. It has been tested daily since it came back with no problems).
Now, you voice incorrect information on MTStars. Your problem is in your computer.
Please feel free to call us yet again if this is not clear to you.
Tom Wilkes
President
Executive Communication Systems
(800) 644-9525, ext. 101
Try expunging the felony record. sm
My friend's daughter did this after being turned down for a job at Target. She was an adult. You will need some legal assistance to do it.
It's probably an electronic health record.
They probably got an electronic health record where it is basically a point and click system that creates a progress note, does the coding, etc. I think this is going to hurt transcription greatly.
In Microsoft Word, there should be a record
of changes made and who accessed the report and made it. SOmeone with more technical expertise should be able to tell you what you do.
IT users?? Need ideas on how to record (sm)
the rad report MR#s, DVI#s, Accession #s in IT so to save me time. This is radiology and at times, recording the exam numbers takes longer than typing the report, so hopefully, you understand.
My idea is to open a daily list on the blank page of the IT screen and then save it at the end of the day. Does this sound plausible to you?
Thanks for your feedback!
Rad MT
After 5 years, you can have your record expunged. sm
If you apply for some high-level security position, such as law enforcement, FBI, etc., it will still show up, but otherwise, you can trully answer "no" if asked if you have any convictions, etc. You do have to go through an attorney, and I do not know how much it costs.
Hope this helps.
Re-record and C-phone question...sm
Hi all!
If I have an account that requires a C-phone, would I have to re-record it?
Isn't re-recording very time consuming?
It's been a while since I worked with a C-phone, but I don't remember having to re-record, and I just remember hearing folks on these boards talk about how time consuming this can be and how the sound quality can be different.
TIA for any expertise!
I use / and record a macro which I assign
to an F key. Then I put / wherever in the template I need to input.
So moving around is as simple as pushing the F2 key as many times as needed...
I also use the macro record and assign to an F key functions like block and copy. Then if you have to move a whole section of words to another page, it's one key to block and copy and one click of the mouse to paste and you're done.
Unless you are the primary record-keeper sm
You should dispose of all of them. My rule of thumb for files that I keep on my computer is two weeks. I send them in daily to the clinic, but I do keep mine for two weeks as backup in case for some reason theirs get lost.
You need to dispose of them so that the information can no longer be extracted. I remember a long time ago we had a magnet we would run tapes and/or disks through which would wipe the data. I don't know if those still exist, or how well they actually work.
You might get in touch with the MTSO or clinic or whoever the information originally belonged to and find out how they dispose of their sensitive material.
You need two macros. Just record the steps
to change to higher level, and the second one to change it back. Be sure to assign shortcut keys to each.
Telephone Record Adaptor
You might want to look into getting a telephone record adaptor that plugs into your laptop sound card. Also would require audio capture software but then the files would be recorded onto your computer and from there you could transcribe them.
How to re-record off phone line?
Does anyone know how to re-record transcription off a phone line? TIA
He did not start the electronic record, really
Why beat a dead horse? I have been on electronic records for years now, before him. I think you are a hater and any and everything you can find to say about him you will. This is NOT NEW with electronic records. Find something else to gripe about, ok?
If the law requires that a patient's record be
protected by HIPAA, and HIPAA laws have no effect overseas, wouldn't it logically be a violation to send the record overseas?
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