Clinic Note formatting question...
Posted By: New MT on 2006-09-09
In Reply to:
If the patient has a drug allergy do I make a new heading for Allergies or just include it in the HPI as dictated? Also do I put the medication in all caps w/in the HPI if it is left there.
I know I should probably know this,but I can not remember tonight. 
TIA!
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clinic is not walk-in or ER notes; it is clinic
could be a small clinic with just famiy practice, internal medicine, maybe physical therapy, or it could be like mine, large, every speciality, cardio, nephro, neuro, ortho, endo, surgery, ENT, podiatry, ophtho, derm...
XML formatting - does anyone know how....sm
to create a double space after punctuation that holds and doesn't get stripped in XML? Thanks!
formatting
Generally, if you don't have to identify the speakers by name or if there are several speakers -- just start a new paragraph with each change of speaker. Or, if it is a question/answer type of interview, you can put Question and Response as headings on each new paragraph. I've even done them with Male and Female headings to identify speakers when the company didn't want them identified by their names. Good luck.
Formatting
I have a few questions about formatting:
If more than 1 presciption is dictated should it be seperated with a period or a comma? For example: Prozac 100 mg. , Provigil 200 mg.
Thanks
Angie
SH bold formatting and others
In the "Dictionary Text [Add]" dialog box, as you
are entering in the "Text to Type", when you need
to add special formatting, you simply tap Ctrl-K, and
add the keystroke commands applicable to your
word processor to change to the desired font.
For example, Microsoft Word uses Ctrl+B to
enable/disable bold face. So to simulate bold text
with ShortHand in Microsoft Word, you simply need
to simulate the Ctrl+B keystroke. When you are done
your word(s) that are bolded will look like this:
{@KEY--Ctrl+B}your text{@KEY--Ctrl+B}.
When you actually type the key (as you transcribe)
Shorthand will automatically/instantly enter all the
special function keys that you have entered, and
your text will come out formatted.
You can use the same concept to add any formatting codes to your Shorthand text, including underlining, italicizing, changing font styles and/or font sizes. You can also add tabs, change margins, etc.
Try thi out and if you have any problems with this, post another message.
ask about that and formatting b4 you start -nm
.
AAMT BOS Formatting Question
Can any MTs with the AAMT BOS 2nd Ed. tell me the recommended way of formatting headings and operative titles? TIA 
Meditech Formatting Keys
I think it was control F8 for spellcheck, but you must be at the top of the document within the text portion of the report. I have an old cardboard that fit over my F keys. Here is what is says: Control: SI, Add Line, Left Justify, Conv Case, Transpose, Del BOW, Del BOW, blank, S3, Word Attr, S19. Then for Shift: Bold, Italic, Underline, Set Attr, Center, Join, Help, Docum, Set Search, Search, Replace, MAGIC. Then across the bottom it says: Begin Block, End Block, Format, Get, Recall, Prev Field, Begin, End, Lookup, Delete Line, Exit, OK. I hope this makes sense. I basically had this placed overtop my F keys, and then I used this as a guide. I think the post you were asking about was for the spellcheck. I only worked in MAGIC Meditech, not in CLIENT, which is apparently word-based, so I'm not sure if these functions work the same in CLIENT. Good luck.  E-mail me if ya' like - I am long time Meditech user (10+ years), but it has been a few months, and I haven't had to use it.
Need help setting up formatting in MS word - sm
Computer crashed and died and now setting up my backup computer. I need to fix it so I don't have 2 spaces after a period. It is doing it automatically and I cannot find where to "fix" this. This is Word 2000 that I am using on a computer with XP Pro. Any help with this would be appreciated, it is driving me nuts (I am ending up with 3 spaces after a period as I am so used to spacing it myself).
Needing assistance with formatting
Asked to go to word, tools autoformant and disable autonumber but cannot locate this. Can anyone help?
Did you look at the margins and formatting and see how your basic template is set up? Never had this
s
Need advice please re: formatting transcription test
It's been a long time since I had to do this. I've been given a couple of report types to do. The first appears to be a discharge summary. Should I just type in the headings the way I "think" they should be based on how I was taught in the past??
Also, is it best to transcribe verbatim or try to make the test report look as professional as possible (like we would be expected to when on the job)? As far as listed items are concerned, i.e. medications.....The old MT in me wants to number them. Is that acceptable? I'm really concerned with trying to format the report based on how I "think" they would want me to.
I would appreciate any helpful advice anyone is willing to share!!
I agree 100%. Test questions on formatting or
anything else should not be asked on a forum of any kind. You need to research and find the answers for yourself on a test and not rely on people here to do the work for you.
I work for a hospital that is pretty liberal as far as formatting goes. SM
They have a basic template that they like us to adhere to as far as headings, font, font size, etc. However, when it comes to more detailed formatting, they really have no set standards and leave it to our best judgment.
My question is regarding the medication heading. Do you list the medications in a numbered list or in paragraph form? I have a friend who is a nurse and she says the clinical staff, i.e. Nurses and Doctors like to have the medications in a numbered list because it makes finding them in a report a whole lot easier. So would you list them even if the dictator is not saying "number 1, 2, 3,..."?
Macros are better suited to repetitive tasks like formatting.
I have a macro to create a different second page of a letter with header info., another one that will update formatting from documents created using a different Normal template so they conform with mine, another one for highlighting, etc. They really can be timesavers.
It means you have special formatting applied to those paragraphs sm
like keep lines together or keep with next. You can turn those squares off with the show/hide button on the toolbar or hit Ctrl+Shift +8 to toggle marks on or off -- that's probably what you hit to turn them on.
Basically formatting, how to type the headings, numbering, etc...sm
Are headings capitalized or followed with a colon?
ex.
HISTORY OF THE PRESENT ILLNESS:
Is it p.r.n., prn, h.s. or bedtime?
Just your basic formatting and styles. I may just download the ebook. Thanks!
Formatting of the document dictates the line count, not a different computer.
xx
If you're working in Word, if your Standard & Formatting toolbars
s
Any Stedman SmartType users? Pros & Cons? Will it retain bold formatting without using DOS command
DOS commands like ShortHand does?
Basically, harder dictators and harder reports with a lot of formatting with tables, etc. SM
give you extra lines because of the time involved in doing those particular reports. Not so much you get paid more per line, you just get extra line credit. For example:
You have a 100 line report, but it is weighted because of a table that you have to input. Then you would maybe get credit for 130 lines for that report.
Thanks for your note. SM
I think this problem must be specific to my particular account. I have tried all the things we were told, clearing, entering new names to try, etc. Thanks again.
Note to MQ: What would be
retired MTs in your workflow room and being TC's.>?
I am so tired of dealing with haughty people who don't have a clue
why I need something or what I do - and on top of them coping an
attitude with me because I get exasperated with their inability
to do their job which is make the work flow.
If MQ had people hired in their work flow areas who had worked inside
the world of transcription and knew where it goes in a hospital,
what to look at on the screens of the machines in the work flow rooms,
etc etc we wouldn't be getting hysterical messages all the time about
not meeting turn around times.
But no! they want to hire first-time jobbers to be in control of the lives
of people who have been in the business usually upwards of 15 years
in order to even do this MT job at home with no help or assistance -
and then make us put up with them and at the same time try to make a living.
I don't want a doctor operating me who has never been inside a hospital, and I
am sick to death of dealing with people in a transcription company
who has never been inside a hospital and followed a REPORT around.
They need to see WHY A REPORT is done - HOW IT IS DONE
They need to go to dictate stations - they need to go in a medical records
area and look at charts - go inside an OR - and into the ICU
they need to see how the world of medicine is and how it operates.
Only then will they understand TATs, reports, and why things are done as they
are or at least why people want them done a certain way.
Like if I keep getting dictations with LOUD BUZZING - i don't want to keep getting
LOUD BUZZING - I want to let the hospital know there is probably a bad phone
instrument - and if this work flow person sees where dictation is done he will
understand it wouldn't take much to MAKE THE BUZZING STOP - and not get
pissy with me because I'd like to talk to somebody about LOUD BUZZING ON
REPORTS. - It's not rocket science - just need to let somebody know.
I know this isn't a note, but
maybe this will be of some help, I'm still searching for a note.
Breast-Related Medical Terms
GLOSSARY OF MEDICAL TERMS
Areola The pigmented or darker colored area of skin surrounding the nipple of the breast.
Asymmetry A lack of proportion of shape, size and position on opposite sides of the body.
Autoimmune Disease A disease in which the body mounts an "attack," disease response to its own tissues or cell types. Normally, the body's immune mechanism is able to distinguish clearly between what is a normal substance and what is foreign. In autoimmune diseases, this system becomes defective and produces antibodies against normal parts of the body, causing tissue injury. Certain diseases such as rheumatoid arthritis and scleroderma are considered to be autoimmune diseases.
Axillary Pertaining to the armpit area.
Bilateral Pertaining to both the left and right breast.
Biopsy Removal and examination of sample tissue for diagnosis.
Breast Augmentation Enlargement of the breast by surgical implantation of a breast implant or patient's own tissue.
Breast Reconstruction Surgical restoration of natural breast contour and mass following mastectomy, trauma or injury.
Capsular Contracture Tightening of the tissue surrounding a breast implant which results in a firmer breast.
Capsulectomy Surgical removal of the entire capsule surrounding a breast implant.
Capsulotomy Closed Capsulotomy: Compression on the outside of the breast to break the capsule and relieve contracture.
Open Capsulotomy: Surgically cutting or removing part of the capsule through an incision.
Carcinoma Invasive malignant tumor.
Congenita Anomaly Abnormality existing at birth.
Connective Tissue Disease(CTD) A disease or group of diseases affecting connective tissue. The cause of these diseases is unknown. The diseases are grouped together on the basis of clinical signs, symptoms, and laboratory abnormalities.
Deflation/Rupture Refers to loss of saline from a saline-filled breast implant due to a tear or cut in the implant shell or possibly a valve leak.
Displacement Shifting in the original position.
Epidemiological Pertaining to the cause, distribution and control of disease in populations.
Extrusion A breast implant or tissue Expander being pressed out of the body.
Fibrous Tissue Tissue resembling fibers.
Hematoma A swelling or mass of blood (usually clotted) confined to an organ, tissue, or space and caused by a break in a blood vessel.
Immune Response The reaction of the body to substances that are foreign or are interpreted as being foreign.
Inframammary Below the breast.
Inframammary Fold The crease at the base of the breast and the chest wall.
Inframammary Incision A surgical incision at the inframammary fold
In-Patient Surgery Surgery performed in a hospital requiring an overnight stay
Latissimus Dorsi Two triangular muscles running from the spinal column to the shoulder.
Mammography Use of radiography (X-rays) of the breast to detect breast cancer. Recommended as a screening technique for early detection of breast cancer.
Mastectomy Surgical removal of the breast.
Subcutaneous Mastectomy: Removal of breast tissue, preserving the skin and nipple.
Partial Mastectomy: Removal of primary tumor and a wide margin of tissue, may include the overlying skin and the muscle fibrous tissue (fascia) underlying the tumor.
Total (Simple) Mastectomy: Removal of breast tissue and the nipple; sometimes accompanied by armpit (axillary) node dissection.
Modified Radical Mastectomy: Removal of breast tissue, nipple, and fascia of chest (pectoralis) muscle with axillary node dissection.
Mastopexy Plastic surgery to move sagging (ptotic) breasts into a more elevated position.
Necrosis Death of tissue. May be caused by insufficient blood supply, trauma, radiation, chemical agents or infectious disease.
Oncologist A specialist in the branch of medicine dealing with the study and treatment of tumors.
Out-Patient Surgery Surgery performed in a hospital or surgery center not requiring an overnight stay.
Mammaplasty Plastic surgery of the breast.
Mammary Pertaining to the breast.
Palpate/Palpability To feel with the hand.
Pectoralis The major muscle of the chest.
Plastic Surgery Surgery intended to improve, restore, repair, or reconstruct portions of the body following trauma, injury or illness.
Prosthesis An artificial device used to replace or represent a body part.
Ptosis Sagging of the breast usually due to normal aging, pregnancy or weight loss.
Rectus Abdominus Major abdominal (stomach) muscle.
Saline A solution of sodium chloride (salt) and water.
Seroma Localized collection of serum, the watery portion of blood, that resembles a tumor.
Serratus Muscle located beneath the chest's pectoralis major and minor muscles and the rib cage.
Silicone Elastomer A type of silicone that has elastic properties similar to rubber.
Subglandular Placement Placement of the breast implant behind the skin and mammary gland, but on top of the chest (pectoralis) muscle. Also called prepectoral or retromammary placement.
Submuscular Placement Placement of the breast implant under the chest (pectoralis) muscle, or under the pectoralis and serratus muscles. Also called retropectoral or subpectoral placement.
Surgical Incision Cut made in tissue for surgical purposes.
Transaxillary Incision Incision across the long axis of the armpit (axilla).
Umbilical Relating to the navel.
Unilateral Affecting only left or right breast.
Anyway, sorry, on a more serious note...
as regards your problem: Do you have Ad-Aware and SpyBot and have you run those? If you have run those and are still not finding anything, you might want to try a trial of this program I just downloaded myself and seems to have gotten rid of this darned WinFix (Virtumond?) pop-up problem I've been having recently that my Ad-Aware and Spybot couldn't seem to take care of. Dang, I might actually buy this one! But anyway, you can use it for 2 weeks, I think it is, for free (see link below).
Just a note: There are two MTs that I will not SM
use to this day - 15 years down the road - because they did this. They will never get a recommendation from me and they will never sub for me.
You leave a long trail when you do something like this.
on another note
I know a lot of people believe as you do, but in my family I have seen lots of evidence to contradict this theory.
I don't condemn anyone who overdrinks, but I think we spend too much time in our culture blaming genetics and other people - mostly our parents - for our own poor choices and bad behaviors.
Bottom line is, the alcohol does not force itself into anyone's mouth and neither do the drugs. To me, drugs include not just the street drugs, but the legally obtained prescription drugs that so many people rely on to get them through the day (do not flame me about arthritis meds, etc. taken for legitimate conditions).
P.S. and it's an OP note!
nm
On that same note...
I wonder if any of you report errors you notice in other reports to the QA at your office. I have seen some doozies, but I admit I have been remiss. I just wanted to know what the rest of you do, even if the report is old.
sorry -- BAD day. (no note)
.
NOTE,,,,,,,,,,,,,,,nm
nm
perhaps you could drop your TC a note...sm
just to say hi, and welcome. She/he has many, many more people to get in touch with than you do, so why not make the first move? I'm not at all trying to be ugly, please don't take it that way, it's just, why not just send a message saying hi, and introducing yourself? Just a thought! Good luck with whatever you choose to do!!! 
perhaps you could drop your TC a note...
I guess you mean Transcription Coordinator -- what I called my new supervisor. I hear you, but I really don't see that as my responsiblity. MQ is so chaotic, I always get the impression they'd greatly prefer not to be bothered. I'm kinda way past that point with that. Thanks for the welcome anyhow.
perhaps you could drop your TC a note...
I think you've misunderstood me. I agree completely with your most recent post, i.e. being left alone to do my job. Absolutely. I just don't think a courtesy note from a new supervisor is too much to ask. That's not breathing down my neck; IMO, that's courtesy, i.e. Here I am, I'm your new supervisor, here's how things may or may not change, just wanted to say hi and make proper notation of the fact that a change has taken place. WHATEVER.
perhaps you could drop your TC a note...
Okay, now you're making me mad. You don't know me, and you have no right to lump me into a goup with "(my) fellow nut-case MTs" ...and you have the gall to say "nothing personal"? Freakish behavior? Talk about the pot calling the kettle black! Wow, I came on here looking for some support, and now I'm a freak and a nut case. No thanks! See y'all around!!!
perhaps you could drop your TC a note...
Read your phrase: "your fellow nut-case MTs." It does not say "your fellow MTs, some of whom are nut cases."
Read your phrase: "freakish behavior en masse." It does not say "the freakish behavior of some MTs."
Both of these groupings include me. You are guilty of bad syntax and just plain rudeness. I consider these equally offensive. I most certainly did not fly off of any handle, nor did I (until now) TAKE TO WRITING IN CAPITAL LETTERS TO EXPRESS MY OPPOSITION TO YOUR POINT OF VIEW when a little careful wording would've rendered that unnecessary. I proved you point? You sure proved mine. GOODBYE.
Note for Souzam
Sorry to change the subject, but did you even test for KP? If you have any more questions e-mail me at lilygirl54@adelphia.net.
AN OPEN NOTE TO MTS
1-Do not wonder WHY work is being sent overseas when in screening applications 20 of 25 resumes are full of errors, typos and people applying that do not come NEAR to fitting the job requirements.
2-Do not wonder WHY work is being sent overseas when you are hired to work hours YOU REQUESTED and then you do not even bother to start work, call, email, just nothing.
3-Do not wonder WHY work is being sent overseas when you are tested and screened only to find out that several "friends of friends" circulated the test around and while you do wonderfully on the test, now in the real situation, you can not figure out the difference between discrete and discreet.
4-Do not wonder WHY you were given less and less work, but take a look at the quality of work you produced...full of blanks, not formatted to specifications in the manual sent, skipped reports. When Q*A has to redo 90% of your work, it is easier to quietly phase you out than to continue to "train" a supposedly seasoned MT
5-Do not wonder WHY you were taken off an account, but look at the feedback you were given regarding the continued mistakes with spelling (you do not use the spellcheck as too time consuming - your words), continued mistakes with doctors signatures, names, formats, phrases. Your position is to "pound out lines" and not worry about the quality.
6-Do not wonder WHY no one will hire you...after all, MTSOs communicate with each other too and the same names just seem to cycle through
7-Do not wonder WHY companies look overseas for workers...because at least THEY want to work. They are not taking days off at a time with no notice...leaving a company and client in the lurch.
8-Do not wonder WHY your resume was not answered...you applied before, were tested before and never bothered to answer emails regarding hiring...never bothered to start on your start date...resumes are kept and note made of why someone that seemed very qualified was not hired.
9-Do not wonder WHY you were not hired...remember me? I am the one that tested you, screened you, then talked to you for quite some time on the phone interviewing you. Remember me? I am the one you "sold" yourself to as far as being ethical, good worker, etc., only to find out that you received the hiring package, then contacted the client directly and suddenly, you did not want the job and then I see you are working FOR THEM....
10-Do not wonder WHY you were not hired after taking the test...take a look at the test results and the responses back you made like "that is how I have always done it" and I do not think you are correct because that is not how I was told or trained to do it.
11-Do not wonder WHY you were quietly let go...check your invoices and the inflated lines and/or hours on there? The system SHOWS the reports you ran, lines you did, but you continue to add report numbers not done by you and lines not done by you. AND for bonus hours...you continue to add bonuses that were not earned.
12-Do not wonder WHY I cringe when it comes time to hire again..I cringe because of every MT out there that shows NO RESPECT to a potential employer now or down the road by ignoring remails.....receiving a test, but never taking it...getting a test graded and offered position but never responds back....going through entire hiring process with access codes, start dates and times but then NEVER even starts...or the ones that we PAY a computer guy to get set up and they never start working...or we send software and equipment to and then never get it back or have a legal fight to get it back.
There are two sides to ever story, this I know, but as an MTSO the above are simply a FEW of the hundreds of things experienced in trying to hire just ONE good MT....
Thank you so much for such an encouraging note!
I am going through a separation from my husband. He thinks a sacrifice is giving up going to the local bar when he gets of work, giving up his drunk he has on a daily basis, and just all in all growing up and taking on responsibilities.
I have been so down and depressed lately that I have to FORCE myself to work.
Thank you for being the angel on my shoulder today!
On another note, it is proven that
addictions are hereditary also. I am not saying everyone who has alcoholism in their family will be alcoholics, but you are more likely to suffer from addiction than someone who does not have a family history.
Geez!! Take a note of the pay.
http://seattle.craigslist.org/hea/122382546.html
Isn't being a medical Transcriptionist being an interpreter. Seems like our pay ought to be commensurate, don't you think?
I can't imagine why my note
has all of these hits, especially since it wasn't a general question and had nothing to do with transcription. Must have been a slow work day :)
Op note account
Anybody out there that does surgery notes exclusively and how do you like it? Thanks in advance.
How to get more OP note training
I had dabbled in operative reports quite sparingly at a prior job, really only typing STAT ones that the hospital called about since I was the only Transcriptionist working nights, so I really do not have much experience and dreaded them. I think it would have been easier if I would have had some training or examples prior to just doing them, but they were quite frustrated most of the time. Anyhow, my question is how to get experience on OP notes so they aren't so frightening? I had asked my current employer when I was hired, but they of course (and I understand why, not complaining here) did not want to have to train or 'help' someone. So I type the rest of acute care minus the OP reports. I would like to get some experience on them however, so any feedback would be greatly appreciated. Thanks.
Little red note book? sm
Anybody heard of this? My SIL was offered this program with her Career Step course. She was told that a lot of MTs use this to store important information for future reference. I have been doing in this business for 13 years and have not heard of this program. I told her that I felt if she had adequate reference material, as well as knowledge of several reference web sites, I thought she would be fine. I told her I would ask around though.
So, has anybody used this and if so, was it worthwhile and useful? Thanks!!!
K
You too!! What a sweet note! Thank you.
Looooooooooong note
Did you ever do a note sooooooooo looooooooooooong, that by the time you were at the PHYSICAL EXAM you had forgotten who the patient even was and what was wrong with them, and by the time you got to the IMPRESSION you had forgotten even what day it was, and by the time you finally signed off, you were asking WHO AM I???
Good grief, help this man bring this to a close!!!!! We have every lab value and every sneeze all the way back to birth!!!!
The only good thing is all those lines, but honestly that doctor kept saying, "um, um" like he was afraid to hang up. Well, he COULDN'T hang up. He just added some more.
A little note re: QA/editing...sm
 QA is supposed to be for when you just cannot make out the dictation, and this lends a new pair of ears for listening. Apparently, that is not the case in some companies. It sounds to me that some companies feel QA is "better than" the Transcriptionist in some way and that is sad. Never forget that the QA personnel were most likely transcriptionists themselves, so they should know better than to respond with snide remarks, but well... this is life! So, if QA feels they are better, so be it. As long as a company is not charging or penalizing you for it, then let it go... it is not worth the lost time. If you feel that you are right, then prove it. If not, then let it go, and try to remember for next time. As far as conflicts, present them to your supervisor. If you don't get a response, oh well! At least you tried to do your best. I do believe no one is perfect, and I would have to admit the QA people I have worked with have been very good about my feedback towards their QA tactics. I actually edited an "edited" report, and received an "I'm sorry!" You may be an editor/QA'er one day and think back... hhhmmmm. You know it should really all depend on what the doctor/client would like to see. Samples, samples, samples! Ask for them, and if not provided, then post a reminder with each marker or blank left if possible that a "sample" would be great for new or hard to learn dictators. Most clients will provide them, and remember NO ONE IS PERFECT! I have 17 years of experience and am still learning every day! I feel like I've truly "done it all", but I am always amazed at what I learn each and every day! Please try also to remember we are in health care no matter you slice it, very unpredictable! Take care everyone...
Positive note
Melissa,
MT is a real, legitimate work-at-home job. You can't do it, usually, without either contacts, past experience or formal training. I formally trained for 7 months and got a job working from home 2 weeks after graduating. The formal training costs are reasonable...and I think anyone would agree with that after the money they've spent on their BA (of which I have one too). If you are serious about this, get formally trained at one of the good on-line schools, and you should have no trouble finding an at-home position. Working with a child or children (as I do) is not easy, but it can work if you want/need it to. You will have to have some help...maybe your spouse or an in-home babysitter sometime, but it beats working full time and leaving your kids in daycare to get pneumonia, of which I speak from experience. Good luck to you in your decision. Becky
Sansie- to your note
I do not work nor do I use anything that hooks to electrical current. I have reached a very nice older age and do not care to do something that would hasten my demise. I am not putting my life on the line for my job- they can blow a gasket if they would like- we had severe storms this past Saturday and several homes in the area hit with lightning and homes burned. You can do what you would like but I sure wouldn't sit hooked to anything electrical during a storm.
Thank you, small note
Who knows when I get my account I will hire the experienced MTs to do QA:-) for my work.
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