I've been off after 3 notes.

• Off QA in 3 days? - lookingformore
  • I've been off after 3 notes. - MslaMT
    • I have done the same SM - Destinyisntfree
    • I hope I can be that good and exp. one day that a company trusts me enough to say hey you don't n - blondie
  • I've been off in 5 hours - nm - mtusa13
  • I do think it's too short but... - smurf
  • Here's the dealio... MTs are expected to be able to hit the ground running. - SM
    • You are right, we do work from home....sm - blondie
    • I was offered a job and they said 3 months paid training - Kathy
      • If they offered 3 months paid training SM - QAer
        • Not sure what you mean by mentoring - Kathy
          • $13/hr is ridiculously low. I suspect SM - QAer
      • Yes. Three months paid training? That's just ridiculous unless you're working - SM
  • No, but with an expander you can just set your expansions to the approved versions for that account. - MissIndigo
  • what company is this please? - nm
  • I have had it as short as 4 hours on QA sm - Happy TTer
  • No, a bit short yeah but not abnormal - sm -
  • what companies are you all working for - ????
    • q.d. will never be correct if the MT SM - QAer
      • I don't agree...sm - blondie
        • They may want verbatim, but if they are in - me
          • Actually, the BOS follows the Joint Commission not vice versa. The BOS... - SM
          • I understand what you mean and agree...sm - blondie
            • I think you need to look up JCAHO SM - QAer
              • It is up to the facility not the MT (eom) - teaser
  • I've only been on QA 1 day at most. I would - me
    • If you have only been on QA for no more than 1 day then you either have extremely easy accounts....s - blondie
      • I have a 2nd job as an MT-never been on SM - QAer
      • I do acute care, all specialities, all - me
        • How long have you been a MT?....nm - blondie
  • In my book, if you can't pick up SM - QAer
    • Never typed an ESL??...sm - blondie
      • Yep, that was me - didn't know how good I had it
      • I think she is talking about full QA review not occasional blanks with a new dictator. - -Libby
  • Are you talking about full QA where you send every report for review? - -sm
    • Not fishy at all sm - Destinyisntfree
      • I think the key to how soon you would get off of QA is exp...sm - blondie

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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! 

used DocQscribe, but I have used Meditech, Cerner, Vianeta, the Precyse platform (I can't remember the name), Dolbey, and  Lanier platform I think was called Cequence (?). 

Out of all the different platforms I have typed on, I have liked EXText the best.  In my opinion, it's very user friendly, easy to learn, and I really like ESP which is the built in abbreviation expander.  Plus it is very easy to create your own normals which I love.  My fingers literally never leave the keyboard because there are macro keys for everything.  You can use your mouse if you prefer or learn the function macros.  I love it.  I think I'm more productive on EXText than with any other platform.

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

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

Good luck!

I love doing op notes. They are very difficult though and i do recommend that you go into them slowly if at all possible. I was doing strictly clinic notes when I came to work here, but lost a girl that did the Op notes and we decided to send our clinic notes out to someone else and I started doing OP notes and other types of dictations. They are my fav.

Mostly clinic notes from my experience:

S - subjective

O - objective

A - assessment

P - plan

Yes that is correct they are chart or clinical notes.  The dentist that I used to work for liked the charts written up in that fashion.

S- subjective

O- objective

A- assessment

P- plan

I may sound dumb, but what is a SOAP note??

Do you mean that they are written notes or are they on a dictaphone system??  I am just wondering why you would need someone close by?  bj

I have that problem once in a while and my doc and I got into an argument about it once. I knew he didn't dictate the notes, but he kept telling me he puts a check mark on the notes he does dictate. 

I've been with this doc since 1995 and I have a phone in system, so if he dictates them, they're transcribed. If he doesn't dictate them, then he didn't do them.

Well, for how busy he is, if he put the check mark on the note PRIOR to dictating, then gets called away for a patient or starts to fall asleep while dictating (which he has done already), it could very easily be overlooked. What aggravates me is that he makes me type Re-dictation on any notes he says he did before but didn't.

Also, I have found that since the last secretary left, there aren't as many "missing notes" as before. Hm-m-m-m. That tells me something. I can understand if I put a blank for the patient name (no list to follow and if it's a new patient or can't understand Speedy Gonzalez, then those notes could very well be thrown away if they can't verify the patient.

I don't print the notes or hand deliver them anymore. We use PCAnywhere, and the notes are in one file with the dates of the notes dictated, which I transfer directly to his computer, so they print them out on their end. I have the notes and so do they, so if they are missing a note, all they have to do is check their files to see if that note is there. If not, then he didn't do it.  End of argument.

This has worked out great for me, but for you, well, I'd think twice about keeping a job with that much aggravation. Find another account.

I have been having an awful time getting straight with my company whether to use parenthesis for (Please see nursing notes.) etc.  I get corrected back and forth whether the word "see" has to be involved or if "per" is enough or even just (Nursing notes.) because it is implied to look there.  (No matter how I do it, eventually someone says it should be done the other way.)

To top it off, now someone else has totally not answered that part of the question but has said it has to be more specific, such as (See nursing notes dated 02/12/2008.)  That, see nursing notes is too vague, so not to used (  ).  I switched to doing it that way, and got corrected again!!

I end up feeling like a pain in the butt because I keep trying to get an answer, but I get so stressed out by constantly being told by a different QA person to do it a different way.

Anyone else with an issue like this?  And, how do you all handle this particular issue?