The actual medical record contains
Posted By: sm on 2009-01-30
In Reply to: Most medical records contain YOUR phone number, - address, names of relatives, and - sm
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.
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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?
I think that is very unprofessional for a medical record. nm
x
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!
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.
But how much do you charge for the actual
cc? He wants me to print out the cc also, and if there is more than one cc I have to print out more than one copy of the note...the notes are usually two pages long, too. Thanks for your help.
Holli
Oh, I don't think it is an actual portrayal either..SM
I'm just saying alternative lifestyles do not bother me, so shows that show that do not bother me. There are people who do not want any type of homosexuals shown on TV, like their kids are going to "turn" gay because they see 2 guys kissing or something. I will say that TV has gotten out of hand a little, but I also don't believe in too much censorship; and yes, this is what America wants to watch, or they wouldn't keep putting the same stuff on the air. I don't let my kids watch anything that is obscene. The fact of life though is that one way or another they are going to see things that you might not want them to see. When things like that happen, it gives you a good opportunity to talk to them about what they are watching. The simple life for example. Any parent who lets their kids watch that show and then never talks about it is just crazy. Kids think it is cool to be stupid, to be rich, to never have to work, to only worry about boys falling all over you. It gives you a good chance to talk to them about life, about how things on TV are not always how they appear to be, etc. Unfortunately, no matter what we do, our kids are going to be exposed to all kinds of stuff, and it is up to us as parents to teach them right from wrong. We need to not rely on the media to only show what we consider right and acceptable. That is our job. Also, in no way am I saying you are doing this or this is what you should or shouldn't do. I am just giving my opinion on TV in general. :o)
PS: To clarify, not the actual job but more what is becoming
And I really just want out :(
Well, if it's due to divorce, you DEFINITELY want an actual
real estate agent. You are thinking of the money you think you could save, but what it will end up turning into is a bigger mess. If you sign a 60 or 90 day contract with a for sale by owner agent (i.e. Help-U-Sell, Assist2Sell, BuyOwner) and all they do is plunk a sign in your yard and give you a lock box then you're not getting much. They don't do a lot of advertising other than on their own website and they might print a few flyers for you.
With the market soft right now, unless you price the house really low just to get rid of it, expect it to sit for 90 to 120 days.
I hope that is not an actual
medical record you posted there. Yikes!
See post below with actual MQ CEO letter.
http://forum.mtstars.com/main/v/1/5201.html
I mean the actual word ALLERGY not the med itself
x
Actual dictation. Made my day.
Excerpt from actual dictation that I received on an 80-year-old man.
"He doesn't have any complaints with the exception of his continued relationship with his wife."
She is talking to the actual place.(nm)
x
Do you ever transcribe in actual dreams? (s/m)
Along a similar, but different thread with regards to the post below about daydreaming or thinking about other things when transcribing, do you ever transcribe in your dreams? Thank goodness it doesn't happen all the time, but sometimes I will have a dream where I'm sitting at the computer and transcribing dictation, and can read all the words in front of me. Is that strange, or what? And I also sometimes dream that I'm reading a book. I guess that's what happens when you're in such a word-oriented profession! 
Ah, but actual statistics and things like that
 make it so less fun for them to WHINE AND WHINE!! Great post! There are some bitter MTs out there. Whew!
I thought Lanier was an actual
I could be wrong. I thought a Lanier was similar to a C-phone.
Oops! it is .06 per actual line
Thanks
Only actual employees get min wage.
The CD is WAY harder than the actual test.
No sweat.
Only hospitals and Diskriter do actual sm
background checks where this information would turn up. They also ask on their applications.
I have never been asked when applying for a service. If the question is not asked, then there must not be a prohibition on felons.
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.
Hope you spell better in the actual reports.
Lets try ALL
Do you work an actual 8 hrs a day if hired for such or is it more like 7 with your breaks, etc. nm
s
Amazing.. I think I will have to look into it. Anyone out there know actual costs for family ins?
Thanks.
They'll probably say lower than actual amount
.
Most of the tests are really easy. Much better than the actual dictation.
x
I use CS and ST, works great. The CS that I use is actual Word -sm
I have heard that Chartscript net, which is the newer version, is different - more like a box that you type in instead of actual Word. I have worked for 2 places using CS now, and it implements the actual Word program. As long as it's not Chartscript net, you should be okay. When working, we're told to open our own version of Word first before we even log into CS because it will save anything there if the report you are working on is lost somehow. When I type in CS, which looks just like my Word, ST is up and running right in CS, just like when typing in my own Word program. No problems with it at all. I know what you mean.....I would haaate to work without ST too. Hope it works out for you!
Actual court reporting or transcribing?
There is a difference in the actually reporting where you sit and court and record. You always see the little ladies typing away on the minitypewriter and the actual court transcription. My friend who do this use the tape or digital recorders, for either court or depositions. They also speech into a little cone type deal (name not important) to make notes of thier own as well as writtent notes as the tapes record up to 4 microphone at a time. They did go to school for this.
I transcribed for a small company locally and would pick up thier overflow. The recent rate seemed to be 1.25 a page but I received 1.35 for medical which they could not understand. You do have to have a special tape transcriber for this. You can buy then new or used but you can also get some that have been company modified. They have to be able to play multiple channels. This could run you anywhere from $300-$800 for player alone.
The difference is VERBATIM. Where we correct for proper English you do not on legal. There are a few tricks with the dates and numbers and such but it's not hard to catch onto. You might check into a local court reporting business and see if they have extra work. It can be time consuming but it is interesting. Some are short, some are long. Court cases longer but I have typed depositions that are up to 100 pages long, but that is double spaced. They had to listen to it while recording, then I listend to transcribe and then they listened a third time to proof it. Here is a sample of how the wording can be...
Q All right. Did you ever see the Cadillac at any point, go into the turn lane?
A No. When -- No. Because, when he came off the car he was right in the road. It was in the through lane.
Q Okay. You went over and talked to Mrs. Hobbs, the lady driving the car. Now tell us exactly what she -- David said tell her -- tell you -- tell her that I’m okay, and what did she say to you about just glancing back or what exactly did she tell you?
A If I’m remembering -- getting it right -- I don’t want to -- but what I’m saying is -- like, I said well David, David told me to come and find out how you were doing and don’t worry about him he’ll be okay and then she said, after a few minutes, like I said, she said like -- to the effect that she glanced off the road and she took her eyes off the road and when she looked back it just happened.
Some of them are hilarious.
Point is if you want to transcribe them you don't have to have any special schooling. My friend has never transcribed in her life and she picked it right up within a week.
Gross line is actual lines. sm
9 cpl if count is by 65 chars is not too much, IMO, for an experienced MT. If counting by gross lines, 7.5 c on a gross line equals about 9 cpl on a 65-char line, so if they use gross lines, it might sound low per line but it equals out in the end. A gross line is any line on the page. In other words, you can use your finger and count each line on the page that has words on it, and that's your line count. Most don't count blank lines. However, a lot depends on what they are including in that line, regardless. Are spaces included if 65-char line? Does the line count software count formatting changes (such as bold, underline, etc) If so, that will increase total line count. If not, it will decrease it. Gross line is usually a better deal unless the company is using a size 9 font or something or decrease the side margins. 11-12 size font with 1" margins is good with gross lines. The only thing that affects gross lines is the side margins or the font size. With 65-char line, font and margins don't affect it, which is why most go with that now. You take total characters (incl spaces if they pay for them, as someone else said) and divide by 65 to get total lines. Another thing to ask, if they use templates or normals, are the lines in those included? If not, that decreases total line count, too.
It's really hard for someone to say "this is the rate you should ask for" though, because there can be so much variability from company to company as far as what they count as a line. Also, is it clinic or acute care work? If clinic, generally easier and same docs all the time, so even at a lower line rate, you might make more in the end if you use expander, normals, templates, etc. Is there a platform or can you use Word and your own expander? If acute care where you have different docs all the time, a lot of ESLs, clunky platform, no Expander program, etc., it might slow you down so even with a higher line rate, you might not make as much in the long run. Therefore, you have to take all of that into consideration to arrive at what line rate you should charge or ask for ... almost have to adjust to each different company or client, really. For clinic work, 8-9 cents per 65-char line can net some good pay. For acute care, you might want more like 10-11 to get the same pay. Hope this all makes sense!
You may find that actual copies of the reports are also useful. sm
I did strictly OPs for two years. There were some doctors that I had to check 4 or 5 different reports for every time, just to find the subtle variations he used. I might have 4 copies of appendectomies for him, and need them all to complete a difficult one. Complete copies really are almost necessary, I think.
A "home" can be an actual house or an apartment. So,
to answer your question, you CAN say YES you rent a home.
The actual amount paid is irrelevant
more, but the value of it is more to them than it is to us. For example, if you make $50 for a week's worth of work, do you think that's a lot in America? Probably not. But ask someone in a third world country if $50 is a lot of money to them and ask what it will buy them.
By offshoring work, the MTSO's are saving big bucks by paying foreign MTs far less than they pay us. Therefore, there are many American MTs willing to accept a lower payrate for their work. Thus, lowering the American standard of pay for this industry. Got it?
actual typing time mess
I know exactly what you mean. We see it in E-mails all the time where I work. Although they aren't enforcing it, they do ask that we work our full shift AND get our lines in. I know Dictaphone Extext tracks your typing time and you can see that when you check your line count. It gets really depressing on the speech editing because actual typing time is a LOT less, so it takes longer to get my time in.
This is another way to get more out of the MTs. I think it's all crap, especially since if you were to go over 40 hours a week you won't get paid!
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.
Yes, but the test files are indicative of the actual work.
If the sound quality was so terrible, you didn't want to work there anyways! Right? I do know how you feel. I brain fahrvegnugened on the difference between brady and tachy. Now, everybody knows that one. I just got momentarily confused on it because I get "deer in the headlight" syndrome on oral testing.
not much actual "data", again it's a point and click thing...sm
it's not like people are actually putting in words, just clicking on the match. I agree with the overall groan about GIGO (garbage in, garbage out) but I don't think it's stemming the tide at all...
The actual operation you're performing is Fill Down.
I should have mentioned that before. It's a shortcut that eliminates the need to copy and paste. It's one of many and is located under the Edit menu. For example, series can be used to increase in increments, like for dates.
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