My dangerous abbreviation sheet doesn't list...sm

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This is the site the BOS recommends visiting, so I did.  It is a long list of stuff fer sure!  Here's the link...just copy and paste it into browser.

http://www.ismp.org/Tools/errorproneabbreviations.pdf

Hope it helps!

applies to written entries on a patient's chart, i.e. nurses' notes, doctor's orders, etc.  For some insane reason, someone somewhere decided to apply it to transcription as well which is just silly.  I work for a facility that has decided not to force transcription to strictly adhere to the dangerous abbreviation list and Joint Commission has not counted it against them in the last three audits.

I will say most MTs where I work do not use qhs, qac or qd.  We expand those out because WE (the transcription department) decided that we should for clarification purposes. 

Go to this website: 

http://www.ismp.org/tools/errorproneabbreviations.pdf 

names without a clear spelling will be written phonetically. Then I go on about my business. You could do 10 more reports in the time it takes to try and hear that stuff.

You need support from your MTSO. That is probably the most important thing. It's sad for you to have to deal with unclear sound files and crappy dictators without any backup from the people you work with.

I have my my own account of three OB-GYNs that use a SOAP sheet type heading on a regular piece of paper. It takes up about 2.5" on the top of the first page of each patient note. It is paper that is purchased from a printing company and they write in the patient's name, vitals, LMP, type of contraception, etc. in the appropriate areas. I have my margins set so I start typing under this info. The problem I have had is these sheets will jam up in any of the three printers I have and I just bought a new all-in-one printer and these sheets will actually get so stuck I have to tear them out of my printer! I know it is because they have been handled, written on, sometimes have corners folded, etc. I normally have a second page I print and sometimes even a third, and I print all the notes at one time or it would take me forever to print out their transcription as I normally have 30-40 pages from each doc! I even made sure the paper I purchased for second, third pages is the same weight as this SOAP heading sheet and it makes no difference. It does not jam with every first page/header page, but it does it on average at least three times while I am printing out one doc's work. This wastes a lot of my time, is frustrating, and I feel it is going to ruin my printer/roller bar with it jamming so badly.

When I spoke with the OM, she said they would quit sending these SOAP sheets with the info on them and then they would just add them to the patient's chart as the first page after I return the transcription. However, I just received a message when I returned home that the docs are not happy with this and do not want it done this way.

When I met with the OM, she said they can change this pre-printed "form" to a half page (which will save them money). I am not exactly sure why they do not like the way things have been changed other than this pertinent info is no longer directly on that first page of the patient's note.

Does anyone have ANY suggestions as to what I could do that they might agree to? I know I had mentioned to the OM when I met with her (to discuss going digital) that perhaps they could use the same form on a half page or even smaller as a label to adhere to the patient note and she said "no way"! They will NOT use adhesive anything. I need to resolve this problem TODAY so sure would appreciate some suggestions/feedback.

TIA.

It's an exam check-off sheet and In the center column, two-thirds of the way down it has them listed as:

Overall Prognosis:
Good Fair Guarded Poor

http://www.n8soft.com/support-files/examdemo.pdf

I hope this helps ease your mind some...it seems it is not the worst.  I'm sorry for what you and your family are going through. 

What might WPW stand for?  All he says is 35-year-old female with a history of WPW.

TIA!

square centimeters, or does it just get typed out?

TIA

I normally use autocorrect, but it is very slow lately, and I think I have about reached my capacity.  I am looking for a good Expander that I will be able to convert my autocorrect to.  Thanks in advance for your opinions!!

Hi - What type of abbreviation program is good?  I used to have Abbreviate, but no longer have it.  Is Foxfire a good program?  Does anyone just use their Word autocorrect strictly?  If you use Word autocorrect - do you know how to copy it and put it on another computer? 

Thanks for any help!!

Your question raises the portability of abbreviation lists when you use different trascription platforms.

Each platform offers a utility where you can create your list of abbreviations, but you don't want to start over and over each time you change platforms.
The solution to this problem is that EITHER these platforms provide you with another utility that lets you convert your list to their format OR you invest in an Expander software like ShortHand or Instant Text that let you use your list practically on all platforms.
With Instant Text you can import your AutoCorrect with a few clicks and then you can use it with EMDAT or any other platform.
Your time is worth money. You may want to evaluate how much it is worth by calculating how much time it takes to redo your list.

Pharmacies make plenty of mistakes on prescriptions and I have never heard of one being shut down.  They aren't any better or more careful at their job than anyone else in health care these days - which is to say, the consumer/patient needs to be on their toes at all times because you simply cannot trust anyone to do their job properly. 

Yes, sloppy writing is responsible for some of these mistakes, which is one of the reasons why many elements of  the AMA, the pharmacist associations, and the pharmaceutical industry are pushing for all drugs to have an individual number assigned, so that medication errors can be eliminated or at least greatly reduced.   Thousands of people are injured, make sick or even die from prescription errors every year.

I have been doing MT since the 1970s and I have seen huge changes in health care.  Most obvious change is that it has become a BUSINESS rather than a human service.  Most if not all involved in health care delivery care foremost about the bottom line and their own "bottoms."   Like one of the posters below, I too have noted how long the disclaimers are at the bottom of the H&P and Consults, particularly by the surgeons and interventionalists. 

When I started MT, almost no report was more than 1 page long.  Now, I sometimes transcribe reports where the "disclaimer" section with risks, benefits, alternatives, possible outcomes explanation is half a page long.   This information is already contained in the consent forms that are signed by the patient, so it is redundant to include it on the dictated report, but more and more MDs are doing it.   I have also noticed, or perhaps it is just my perception, that all dictators are including more information about patient attitude, knowledge and compliance regarding their (the patient's) regarding their medical condition.   Personally, I think that is a good thing - people need to take more responsibility for themselves and stop expecting the doctor to solve all their problems. 

Q.D., QD, q.d., qd (daily) = Mistaken for each other = Write "daily".

I woud say this should over ride anything BOS has to say, but we aim to please the client.  As transcriptionists though we should be aware of these dangerous abbreviations since it can affect a patient's medical record and how it is interpreted.

You can look up expansions for abbreviations.  It also lists normal lab values, symbols and numbers definitions for the deciphering the ShortHand that nurses and other clinical personnel use on the chart.  It even has the JCAHO dangerous abbreviations list.  It just has a lot of little neat functions that I've found helpful.  Here it is:

http://www.medabbrev.com/main.cfm

You're partly right.  Joint Commission has no jurisdiction over a private office setting; however, this was adopted by Joint after it was first given to the national pharmacy assocition.  When a doctor has his/her nurse phone in a prescription or writes one himself regardless of private office or inpatient setting, s/he better follow these guidelines. 

Having worked in a pharmacy, I understand how critical it is to be able to know EXACTLY what the doctor wants the patient to have presribed.  Pharmacy is going down the same path as MT work.  Notice how many insurers allow for your prescriptions to go to a mail order company who will fill up to three months of your prescriptions at a time.  The first line of defense these companies have (well, really just one anymore as they are becoming the MQ of pharmacies), is to scan the prescription.  If it is not written clearly, a body must contact that physician.  Addtionally these mail order companies allow MDs to relay prescriptions online.  These guidelines better be followed or they will be contacted.

Depending on which division within the mail order pharmacy you work, a tech may fill more than 100 prescriptions an hour.  If ONE of those prescriptions is filled incorrectly, it is reported to the State Board of Pharmacy who requires a monetary penalty be forwarded by the company depending on the error classification.  If there are too many errors in a given month, the pharmacy is shut down, the supervising PHARMACIST receives (typically) a $5000 fine and a one month to five year suspension of practice, all actions of which are published and distributed to all 50 states in a monthly newsletter.

To say this is all AAMT's fault is ludicrous.  To say the doctors are not going to change their ways because they have god complexes is ludicrous.  This happened because too many mistakes were being made through haste, bad handwriting, lack of time to thoughtfully write prescriptions, etc.  This is today's reality.  If you do not adapt, you do not survive.  Just ask a Cro-Magnon.

d~

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