I think that is very unprofessional for a medical record. nm
Posted By: deb on 2009-06-06
In Reply to: "May his soul rest in heaven." - CrankyBeach
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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.
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?
Approve what? The information used is already part of the medical record and, therefore,...sm
has already been approved or authenticated or whatever one wants to call 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!
Not funny. Just soo unprofessional.
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Spheris is most unprofessional.
The recruiter had a barking dog in the background and was not very open about answering my questions. Sorry to say, but in my opinion, they are very, very last on my list. 
Very unprofessional IMO to question this.
Just because you dont hear it often doesn't mean you need to find a rule in order not to transcribe it. Totally ridiculous.
No, what is unprofessional is not questioning...
something you are unsure about.
Unprofessional but funny thought, sm
wouldn't it be wild if there was a Tourette's syndrome for transcriptionists, and we could just insert whatever random thought or opinion we had on the patient/dictator.
I'm in the middle of a patient's social history and the doc dictates his occupation, and then in the PE he says he's dignified looking. I mean he's obvious very impressed by his social stature and I would love to say that!
That woman is unprofessional & hopefully she won't be there long (sm)
Since she was hired as a temp and is obviously very unprofessional, sounds like maybe she won't be there for long. Hopefully, for you anyway! It sounds like you have a nice job that you like so don't let someone like that ruin a good thing for you. What goes around comes around, so my bet is she'll be gone before you know it. Best of luck to you!
Another silly, unprofessional response.
What does this prove except that you, as an employee, are small-minded and mean-tempered. I'm betting with an attidue like that, you don't get the raises you "think" you deserve.
The offer is what it is and the poster has to either decide to take it or leave it. Your response is just ridiculous.
Personal insults are unprofessional. nm
......
I too think this is very unprofessional. We at MDI-MD may be a littleon edge to be out of work..sm
to say the least and many of us are probably going to be forced to leave a company we have enjoyed due to that fact, but never at any time have I been treated unfairly or unkindly there. We should all act like the professionals we claim to be.
it WAS unprofessional; probably meant as a cliche, but still offensive to some - nm
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I find a lot of UNPROFESSIONAL people in this profession..
This has happened to me several times. Going so far as to send me programs and such and when contacting them that I am ready to go, never hear from them again.
Management is ridiculous, extremely unprofessional s/m
in my opinion. There are many places out there that are better than this one. The manager is rude and has no idea how to manage or motivate. As for the accounts, I had a ton of ESL, but ESL doesn't bother me at all, so I can't help you there.
I agree. I think it shows compassion and nothing unprofessional about that. nm
nm
Yes, venting generalizations on a message board is about as unprofessional
as a business owner can get. I'm glad I DID NOT apply with this company! Sounds too high maintenance, high stress, negative, dictatorial and critical for me.
It was very unprofessional for the dictating physician to include that statement.
I have never come across such a thing myself, but I wouldn't hesitate to type it.
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!
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