The account I do VR on is verbatim so can't fix sentences. nm
Posted By: Jai on 2007-05-28
In Reply to: Not so much fixing words but sentence structure - MTME
nm
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Well, now if it is a verbatim account and
the dictator said, "during this hospital stay" and the MT transcribed "during this hospitalization" -- that is wrong. It all depends on what the client profile outlines.
is this a verbatim account?....nm
Even on a verbatim account,
It sounds as if he was obviously having trouble organizing his thoughts. This is exactly why I no longer work on verbatim accounts. I like being able to use my brain and be trusted enough to make the necessary corrections.
Is it a verbatim account?
I to am QA and the only way I would take the and out is if it a verbatim account and the doctor did not dictate it. I don't think QA changes things just to make a change. I know I don't.
Obviously you don't have a verbatim account.
The time when MTs were even permitted to translate jargon and expand abbreviations are behind us.
Hey, I forgot to add... I was on verbatim account
The poster below who said she shouts it back at the screen gave me a big laugh..Its seems funny.. if we say it, its okay, but don't let a doctor! I think, "How dare her!" But, I did get a laugh out of it, even though I don't like that word!
The problem is if the account is true verbatim...
I only have one doctor on one account who insists her dictation be transcribed verbatim. She makes TONS of boo-boos, but I type 'em. The trouble there is, doctors like that regularly say really wrong and stupid things, we transcribe verbatim, and they say we transcribed it incorrectly. 
I honestly believe some doctors are just so arrogant they can't EVER admit to making a mistake. I am grateful to have docs who actually thank me for catching their errors. Unfortunately they aren't all so gracious.
Sometimes you just can't win.
Also some companies are caught up in the "no blanks" or "everything must be transcribed" - even if it is totally unintelligible gibberish. So, reports are sent with GUESSES (by QA) with OUR names (initials) on them. Or QA changes something (that we transcribed correctly) and again our initials are on it. Chaps my buns.  Now, QA people (and I QA a bit myself, don't get all uppity. Not ALL QA is like that. 
Thanks to both of you...verbatim account. Has to be as dictated unless in diagnosis.
If it is a verbatim account, I'd vote yes ... although with quotes around it. sm
Do you have a supervisor/liaison/QA person to ask?
I agree ... not really professional. Of course, I still cringe when I have to type "belly" instead of stomach. 
I guess that depends if it is a verbatim account...
I think even so I would type feces....
I should have added to type it as "corneals" if verbatim account.
.
Verbatim is verbatim, but I defintely to the little things to make the doc look better such as..sm
an eye problem instead of a eye problem. I definitely wouldn't change too much. Stick with what they say and only make changes when you absolutely think it is necessary. I took a test last night and have an interview today and this is what I did. FYI, I do clinic work.
Verbatim = verbatim......flag it...NM
x
would it be better to take out one of the (many) in these two sentences?
She advised me that for many, many years she had a tea and toast diet with a very poor protein intake, and admitted to not having consumed milk for many, many years. She also had the habit, as do many patients with osteoporosis, by lying down a great deal during the day to coop with her back pain before finally seeking medical attention.
spacing after sentences
Does everyone space once after the end of a sentence now? My daughter takes keyboarding in high school and I just realized they are not taught to double space after the end of a sentence. Should I then change to single spacing after the end of a sentence?
Anyone use only 1 space after sentences?
This is new to me on one of my jobs. I have always typed 2 spaces after sentences for 25 years. Going to be hard to break this habit now.
You have said in a couple of sentences SM
what I have felt about this field for years now--it is next to impossible to deal in a normal way with most MTs--they have warped personalities and have no concept of how to act in everyday social situations.
How about constructing some proper sentences?
xx
I stick with 2 spaces between sentences - it
and easier for ME to proofread, which results in a more accurate record.
BOS is just a money-making scheme for whoever wrote it. Nothing more.
Well, some accounts call for complete sentences for all. sm
Other accounts call for no abbreviations, spell out everything. So, if the account specifics call for it, the MT is to do it. It is not always the MT or MTSO.
I proof as I go. I read my words and sentences as I go....SM
Never received anything less than a 99% on my regular QA reviews and usually have a 99.8, 99.9, or 100%.
Ya know, some hospitals/accounts want fragmented sentences...sm
Some look at it as a technical document and fragments are okay with them.
Just saying.......
I misworded one of my sentences and left another word out. Please sm ...
I WROTE: "I have been told by former employers that I am well above average and deserve to make more than what I'm making especially if it's obtainable."
What I meant to say was this.."I have been told by former employers and QA that I am well above average. Therefore, I feel will my skill level and experience that I deserve to make more than what I'm currently making, especially if its negotiable."
I was in a huge hurry. I hope I cleared that up. Thanks!
Having IT provide phrases, sentences is its best advantage. Two words together.
But one word? By the time it arrives in the layout screen, you have typed all but the last letter.
claudicatio - semicolon
of the - bracket
I miss Word's auto correct boohoo
1 or 2 spaces @ end of sentences? I have Instant Text put in 2, but I have noticed
that after I upload them to the co. I work for, the extra space is being removed. Do you think that that one little space at the end of each sentence would amount to a hill of beans over the course of a week? Just curious what you think. And before you ask, no this was not disclosed to me before I started working here, however, I made the grave error before being hired of only asking how many characters per line and if spaces were included.
One embellished sentences, another did 200 reports and had 70 kicked back with errors.
dd
Tools>AutoCorrectOptions>Uncheck 'Cap 1st letter of sentences' box. (nm)
x
I have heard of a program for Shorthand that has 90% of all sentences a doctor could use, does anybo
nm
All; heavy dependence on single words and phrases/standard sentences of all lengths. SM
Like San Francisco does, they can be used with any account/any dictator, which is extremely important. Just entering mostly whole reports and sections makes one dependent on that account/that employer and back to square one when it's time to take on a new account or even a new dictator.
I also have dozens and dozens of headers, bolded, unbolded, capped, lower case, etc., in various forms of each, like "Indications" "Indication," "Indications for Procedure," "Indications for Surgery," and so on and on and on.
What is the difference between an acute care account and a multispecialty account??..nm
nm
I've never had a problem switching from account to account.
The problem I had was being switched too soon. If I don't get one account spec solidly in my memory with QA feedback on mistakes before starting another, I get confused. The other problem I had with former jobs was inconsistent QA. One person tells you one thing, another person tells you another.
Lately, I don't have a problem with it. Right now, my binder has 8 account specs (some I've never had to use) and I'm picking up a new weekend job for a while. The terminology and report formats stay basically the same. It's just all those little preferences. LOL
Verbatim for ESL too?
Geez, if that were the case on my account (not MQ), you wouldn't believe the crap I'd be putting out - "59 years old pt, denies of chest pain, comes to ER for short of breath," and I could go on and on.
Verbatim
I still don't understand, for example I have a doc who does about 20 lengthy bypass operations a week. I have a 4-page "standard", that I just immediately pull up. He never dictates it the same way twice, I just simply pull up my standard, put ears on, follow along and delete, insert, change and so on as he dictates, and that is as good as verbatim.
Since I am on verbatim also, I use whatever s/he says..
Jim for James etc....however, if the doc is clearly off track, he starts calling Mary by the name of Frank for instance (it has happened) then I flag it.
verbatim
The docs at a big teaching hospital I formerly worked for did not put punctuation marks after the word HOWEVER. That's the way they wanted it and we were marked down if we added the comma.
verbatim, really?
Of course verbatim means typing EVERY SINGLE word they say, even when it's a side conversation, a snide comment, etc. One thing I do that may not help them at all but makes me feel that I've at least let them know that I know - I enclose such words in quote marks to set them off from the real words.
Verbatim
As a private IC there was a prominent heart surgeon from Iran whose dictation I "cleaned up" constantly or he would have been the laughing stock of the community. Sometimes you have to "save face" for the client. If I worked for a national and they QA'd me from saving someone from a drastic error, I would immediately "quit." Another ESL went to hospital admin to tell them I was "his friend," I did not change the meaning but there were several instances when I had to make sense of things for him to cover the hospital's reputation. I was taught never to "change the meaning" and to put certain language "in quotes" although as an IC, I would always call the client first and they usually thanked me. When you work for another service, you can't do this, so it makes it very difficult.I guess you have to go with who pays you, but I would never, never type a senseless sentence.Good luck to those who have "bad QA assessments." They should know better.
verbatim
it's stupid and dangerous to type verbatim. Some hospitals stupidly insist on it cuz they believe we can't think for ourselves. They say "We've always done it that way." Well God forbid you should TRY TO IMPROVE. they say "well, you don't KNOW what he meant." My answer to that is "well, YOU may not know, but I do!" They just don't want to be bothered with having to actually think about it. Any decent trx with many years' experience and worth her salt GENERALLY knows what the doc really means but can't spit out, for one reason or another. I'm married to a doc - I know. But he DOES want us to leave blanks if we DON'T KNOW - better that than making something up, which he does see all the time from Spheris trxs. That's what happens when you hire people with one year of experience and don't monitor them closely, of which Spheris is guilty. And leaving a message for them on ESA doesn't work, cuz the doc won't see it till he goes to sign if off, and by that time, he has no earthly idea what he said. Nor does he care!
IF they got verbatim EXACTLY what they said,
they'd probably be in total shock at how ridiculous they actually sound when they dictate. Don't you just want to give them what they give you sometimes?
Verbatim
The problem is with the client profile. It should not ever have the word "verbatim" in it because the word by definition means "word for word" and we all know all of us from time to time and doctors especially speak garbage and have to be cleaned up. If with followed the client profile and transcribed "verbatim," screams would echo across the country. So I am all for removing that word from all the client profiles unless they truly want reports transcribed verbatim, word for word. We could do that, but it would not be much of a record.
verbatim, no BOS sm
Who are they? I would love to throw the BOS out the window, please e-mail me. Sick of all the new rules which don't amount to a hill of beans anyway at most times.
verbatim
I must be getting old. I'm finding it more and more difficult to "follow directions" as I age regarding this subject. I can't believe these younger physicians don't want us to fix the glaring errors. The real trouble is there's no one who will be the intermediary between the transriber and the doc, maybe, like back in the day. Way too many cooks stirring the broth and complicating what used to be a common-sense and less complicated situation, transcribing, that is.
i do verbatim too, but still BOS has
many points of reference that are helpful. I am one that hated the idea of a BOS, but when i finally succumbed, found there was a lot of useful info in it. Its not a bad idea to have a common reference point.
They may want verbatim, but if they are in
an acute care facility BOS overrides what they want. JCAHO can give/withhold accreditation based on the medical records and they say follow BOS. It isn't that is is an issue of style as much as it is a patient safety issue.
Verbatim
The hospital I work for now is a verbatim account, but we were told to spell out everything in DX, Impression, etc. I spelled out a lab abbrev and it looked so weird, but QA/Trainer told me to spell it out. Very contradictory so if it ever comes back as getting "dinged" for it I am going to tell QA who told me and they better not takes points off my audit.
verbatim is hard for me too
It is very hard for me to deliberately type wrong words, phrases, etc. It makes me think someday someone is going to read that document and say "gads where did they get that transcrptionist!" not knowing we have to type it as dictated.
verbatim accounts
I thought the idea was to correct their poor dictation in most circumstances...I'm wondering why any client would prefer it verbatim, for legal reasons?
that is verbatim. QAs are only human too. nm
you could fix it if you wanted to or is it verbatim? nm
:
Seriously, do you *really* type verbatim? sm
I don't. I'm supposed to, but I've told my super that nothing with my initials on it will ever read like "Patient hand swollen." Yep, I take some liberties. I clean things up, I've added in words, taken some out, rearranged words. I think count-wise it comes out even because I'm not padding and I remove words probably about as often as I add them.
If you are on a verbatim account, are you really typing "Obese patient older than says age, no toxic"?
Only typed verbatim twice
once for a Russian infectious disease MD. After one week of strict verbatim reports, evidently she got a talking to by the senior partner and her style became acceptable.
The hospital is one of the larget and most respected hospitals in the US. All residents much pass a week-long course dedicated strictly to how to chart, how to document, how to dictate. Each resident must personally sign his/her own name daily on a log in sheet and anyone who misses a day does not get to start with the rest of peers. One day is devoted SOLEY to HOW TO DICTATE and accepting full legal responsibility for the dictation. They have to sign an agreement that the hospital will not provide legal support if their documentation falls short of their standards and the resident has to provide his/her own funding against any lawsuit. If they dictate a reversal of pulse rate/respiratory rate, I could switch them, but I had to send it to QA who attached a note to the dictator covering the MTSO from any repercution.
Best dictators I EVER had!
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