Clinic notes questions

• Clinic notes questions - jmr
  • Pay is the same for me. - Msla MT
  • Could be by specialty, but usually walk-in clinic, stand-alone - ER facilities, stuff like that. Pay is lower. NM
    • clinic is not walk-in or ER notes; it is clinic - with speciality...depends on size....

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would be a good place to start, either working as an IC/employee for a national or getting your own accounts.

Good luck!

Mostly clinic notes from my experience:

S - subjective

O - objective

A - assessment

P - plan

number of doctors usually and for the most part there isn't a lot of medical terminology and they have lots of normals, which is good because they you can have lots of macros/expanders to help, but I like learning from my dictation.  With clinic notes I did know when viruses/illnesses were going around and what the standard treatment was, so I could try some of the same treatments if we got sick without a doctor visit, just after a while they were just boring.  I much prefer acute care. I have lots of dictators so I don't get sick of hearing one doctor all day, although occasionally I do get a slew of the same dictator, the terminology is constantly changing, new drugs, new equipment, new procedures, etc.

Has anyone gone from doing clinic notes for different specialities to acute care in a hospital?  I have been a Transcriptionist for four years and lost most of my work to India.  I went back to medical billing for about 5 months and have been offered a position to work at home for a hospital.  I never did hospital work.  This will exclude lab and X-ray reports.  I am a little scared.  Any good sites to brush up on for documents or any words of wisdom?

Thanks!!

I type the clinic notes at home, print them, verify the all notes printed, place them in a manila envelope clearly marked with the clinic name and dictator doctor's name and date of clinic.  I then deliver the notes to the lead Transcriptionist at the hospital which manages the clinics.  She in turn distributes them to the clinics. 

The last two weeks, I have gotten several calls from the lead MT that I give the work too that clinics are calling saying they are missing certain notes from certain days which is impossible because I type all notes for a specific day in one large document and print them out together.  There is no way that some are printing and some are not.  Plus I ALWAYS verify that each note printed.  Today, she called and said there were missing notes from two different days.

Then there is the issue of my work being typed by someone in the hospital.  When I deliver work I get a print out of what's on the system as far as clinic notes.  It is a worktype specific list that only I am supposed type.  There are a couple of doctors who dictate all their notes in one looooong job.  There were two very long jobs on my list, but were never pooled to me.  When I enter the specific job number, it says they have been transcribed.  In one instance, the dictator dictated half on one job and half on another.  I typed one job and the other just magically got transcribed.  When I've called to ask who's typing these reports, no one seems to know.

These ladies in this particular transcription department are not a friendly bunch.  I have felt that they sort of resent the fact that I am doing work from home while they have to come in and type.  I think they are wondering why they aren't allowed to work from home.  The work I do is very easy clinic work and would be pretty easy lines for one of them to do just to pad their line counts.

I have a meeting tomorrow with the HIM director who contracted with me about TAT and I know they want a shorter TAT than the agreed upon 24 to 48 hours and I know she is going to want me to make more deliveries than the three I do a week now.  I have asked that they set up a remote printer for me so I can print from home that way delivery isn't an issue anymore, but they act like this can't be done which I know it can be done.

I'm about to cut this account loose, but it's such easy work.  It's just that I'm running into brick walls at this place.

Thanks for listening to me whine! 

I just recently went back to work in the office at a local hospital. We type in both Meditech and Cerner, depending on what you are typing, i.e. Medical Records reports versus Radiology.  We are currently typing blindly in Meditech, meaning we do not have access to our line counts and must depend on management to give us our totals.  In Cerner, we are able to run a line count report and print out a hard copy of our line counts at the end of the day.

We are finding that 800 lines in Cerner equals about 500 lines in Meditech.  We are not paid per line nor do we have an incentive plan, but we have a new HIM Director who would like to institute an incentive plan and the administrator over our department has laid down the law and decreed that all transcriptionists not making minimum in the department will be written up.  Problem is according to Meditech line totals that we have been given, that would be about half the department.

The transcription supervisor has taken our concerns to the new director who told the MT Supervisor to hold off on writing people and has taken home all the line counts from the last month and she is going over them with a fine tooth comb this weekend.

I am not a very trusting soul by nature, so I am doing a little research on my own.  I've been in this business for about 15 years.  I started out in a hospital and have worked for a few services at home and am now back in the hospital setting.  So I know a few things about line count and I consider myself to be pretty well informed on trends and technology in the industry.   I would like to walk into our next department meeting armed with as much knowledge as possible.  So I have come up with some questions that I would like some fellow MTs to answer, give opinions, and maybe even direct me to websites or individuals who could give me a better understanding of Meditech and Cerner.  Here are my questions:

1. Is it possible for an MT to have access to her line count in Meditech or is strictly a management function?  Any MTs that work in Meditech on this board, do you currently have access to your line counts and if so, how do you check them?  Is it an option on the main menu after you log into Meditech?


2. How is a line defined in Meditech?  (i.e. 65 cpl, with spaces, without spaces)


3. How is a line defined in Cerner?


4. What abbreviation Expanders work with both Meditech and Cerner?


5. Examples of incentive plans (if anyone would like to share that with me that would be great, if not I completely understand).


6. Measuring productivity by minutes of dictation versus typed lines.




1. What would be the minimum minutes required for an 8-hour day?


2. How would one structure an incentive program based on minutes?

I was thinking of presenting the idea that we keep track of productivity using minutes instead of lines since there is such a discrepancy in Meditech.  I also worry that if an incentive plan is put into place and we are still typing blind into Meditech, what's to keep management from shaving off a few lines here and there?

Feel free to email me or post here any responses.  Either is fine.  I really appreciate any input, comments, or just plain old supportive posts would be nice too! 

Don't worry.  It has been my experience being a Transcriptionist for a huge hospital that I loved the ER notes the most.  They are really pretty much abbreviated H&P's and are sometimes the most interesting reports of all.  Not nearly as difficult as some surgeries or discharges notes can be.  Simple and brief and sometimes a really good story.

I do two internal medicine Docs, SOAP notes only and minor procedures and love it  I also did other specialities, but all that was lost to outsourcing to INDIA!

I love doing OP notes. They are so interesting. Anyway there is a website that I use now and then and it is

www.mt911.com it also has samples.com on it and has alot of different samples.

Also a good reference book is The surgical word book by Saunders.

Hope this helps.

Any good sites for OP notes?

thanks Lori

Does anybody have any tips on the best places to specialize in op notes?   I need a place where I can do heavy volume ops -- not interested in basic 4 stuff.

Thanks.

Was wondering if anyone could help me out.  I need to see some example of different ways to set up chart notes.  If anyone knows of a place on the net i can view these of would send me some blanked out that would be great!!!!!

Thanks,

Jackie