Usually if it's a no patient name
Posted By: allowed acct, no relative, etc. names on 2009-01-30
In Reply to: PHI ? about first names in report - Rusty MT
allowed either.
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Putting patient versus The patient (sm)
When did this "rule" come about? I've been an MT/Editor/medeical records tech/ART for 30 years - Never, ever was I told to put that. You cannot make the sentence be "The patient sent to Radiology" but you can put "Patient sent to Radiology."
Thats just insane.
Is the patient
x
patient name
It's surprising your company lets you put the name in the report. The trend has been to use "the patient" instead of the name.
The patient is...
The patient is a 2-month-old elephant.
The patient is a 2-month-old infant.
Work from India.
The patient will . . .
be maintained on a clear liquid diet. He is specifically instructed that beer does not constitute a clear liquid. (pt in for alcoholic gastritis) Still chuckle every time I think of that one!
Also that few MDs can say a patient is
slurring without stuttering or slurring the word, "slurring."
the patient
The client preference is to type "the pateint" To be even more exact, my account instructions state: "NEVER put patient's name in the body of the report, even if it is dictated. Always put 'the patient.'"
yea, but me as a patient...
when i asked to have copies of my medical records, i was APPALLED at the crap that was in them, by this I mean the errors ran rampant throughout, even if it was just a capitalization error, or incomplete sentences (which i consider errors).
I did not like what I saw at all, but would the average person care, if it doesn't change the meaning?
Patient logs
We are required to do a log for each batch of reports that we do. I will fill the info on the report and then control + end to the log and record the same info. Says time for me at the end of the whole document.
Patient info?
Where is my post on typing in patient information???????????
It took me 30 minutes to look-up a patient.
x
All FIVE of the patient's extremities....
Okey, dokey. This one's American, too.
Yes, and patient demographics.
I'm not going to compare myself to others, though. I've made a lot of progress, and that's all that counts. I've only been on this account for three months. Who's to say what I'll be able to do next year?
My doc would put that patient on protinix --nm
x
patient names
This is a problem that I am currently struggling with. My accounts are not 'searchable' and some docs don't spell out the patient's names. I have QC'd these many times with a note AND my e-mail address asking QC if I should be sending all these reports to them minus the patient's name, or send it to them GUESSING the spelling, or just spell the names phonetically and NOT QC them. About 15 requests now, and NO REPLY!! Very frustrating!!! Otherwise, the account is really good. I am new, so did not realize that other platforms gave credit for footers, headers, etc. I know on DQS you get a fair line count on just the body of the report. Don't know about the rest.
when I can't figure out the patient name (sm)
I just leave it blank because, like the other post said, I cannot get any feedback on what is protocol, so I make up my own. I aint gettin' paid enough to fool around trying to figure out what the dumb doc is saying!
Wow, I think I have PMS or something..I don't usually gripe this much! 
Patient Names
You'd be surprised how many facilities have the patient's name on the report. Its not that uncommon. Depends on the facility and the company you work for.
No patient transfered to the LSU
I'm in the procedure section where I cannot abbreviate...Help
RE No patient transfered to the LSU
ICU or CCU maybe - Intensive Care Unit, Coronary Care Unit, can't guess what LSU is in relationship to other than what was said above about football.
The patient is a male
The doctor said: "He denies bloody or cloudy urine, pain with urination and vaginal bleeding."
I crack up laughing and quote this to my husband, stating the patient's gender.
And his response was, "I hope so."
(think about it) 
This is actually between the doctor and patient.
Your job is to transcribe what the doctor wants. He's the one who needs to be compliant by having the paperwork in order to send these copies on. It's not your problem.
Probably something in patient care, maybe CNA. sm
They make about as much as I am making and with benefits on top of that at the hospitals around here.
Tks you all for being so patient. Looks like I'm out to buy WORD. I
computer and I don't see much, and nothing that says "autocorrect" or auto anything.
Yes, after being jerked around for several months now and starving to death I will feel better to get my feet on solid ground again with a local company that I know will be around and I know what the rules are (wink wink).
I'm off to find WORD. ((I don't know how people who have no time with computers at all, get geared up to work for MQ and do all this stuff with no help. I know a little bit/very little! and I just can't imagine just starting to work on a computer))
How old was your oldest patient? sm
Doesn't matter if it is someone you took care of or someone you typed a report about. I just did a report on a 103-year-old man and once while working as a aide, had a 104-year-old male patient. Cute as a button and sharp as a tack. Also had a 101-year-old lady at the nursing home. 
As MTs, our #1 priority is the patient, just
as it should be for doctors, nurses and health care professionals. I know how frustrating it can be trying to translate broken English, etc. I complain about it, too!! Sometimes I get so angry, because it actually takes money out of my pocket in that I spend so much time trying to "get it right" instead of just using my knowledge and typing skills typing dictation from a clear-speaking doctor with good English. Sometimes you want to just scream!!!  BUT, again, it is part of our job to provide an accurate and presentable medical document. I wish things were different, but it appears that we have to work with what we've got or learn a new profession.
That is my humble opinion. 
Pain Patient - Where are you??
I have been SO WORRIED about that lady last week who was withdrawining on her own from OxyContin and was gonna go alone to a hotel and float in their pool, supposedly with a load of VALIUM that was recommended to her on this board! Good Lord!! I just pray she is not dead. Seriously. I tried and tried to post, but was banned for some unknown reason. At any rate, if you are out there, please let us know you are OK. Also, PLEASE don't withdraw from these meds on your own - you can easily seize from opiate withdrawal - everyone is different, and no way should you take VALIUM. NO WAY. I am a huge pain management buff, being in the midst of it myself. Its not safe to do alone - I know - been there done that. The best thing to do is check yourself into one of the 3-day detox programs at any local hospital - no matter who your pain mgmt doctor is. I seriously doubt your doctor wants to keep you addicted, and if you called any authorities and reported that, he'd be in deep trouble. Narcotic scrips are one of the few heavily monitored items today. PLEASE DON'T TAKE VALIUM off scrip. There are outpatient meds like Suboxone - supposed to be a miracle pill. 1 or 2 pills a day, no withdrawal, no urges. Or you can get detoxed under anesthesia in a few hours. Or do the inpatient detox in 3 days with clonidine and possibly Ativan for anxiety. NO VALIUM. And they are set up for giving you the antiseizure meds immediately should you develop seizures, which is common. PLEASE tell me you are OK, and I have given you my email address if you want to write privately. I have been so worried about you. And I 100% totally understand.
PAIN PATIENT
www.pillsanonymous.com
Well, the patient does have some control, actually.
The patient can see another doctor without mentioning seeing this doctor, if he/she believes this MD's opinion is worthless. You can hope the best for the patient, but that's about it. Now if you worked in this MD's office as an employee or you were an IC (I am assuming you are doing hospital work and he is just one of the dictators), then you could decide you didn't want to earn your living from him anymore, but if you are in a service/hospital employee situation, then you just groan when you get him, call him ugly names if you work at home, type his reports, and steer your family and friends toward better MDs whenever possible.
I think most patients can recognize a jerk when they meet one.
The patient has never been pregnant
x
Sounds like she should be a patient there -
First of all, your supervisor(s)/lead(s) or whoever else is overseeing this dept. should be fired. Sounds like it's out of control - but if they are dumb enough to hire her - what do you expect???
If it is a quotation of the patient, I put it in ==sm
quotation marks. If it is not and just something the doc says, I try to change it without losing the context of the report. patient notes are no place for cuss words. I had a question about it one time and asked my supervisor. she said she wanted to know about it, so I flag it. I even had one doc cussing out the Transcriptionist during the dictation for misspelling a word on a prior document, which I thought was rude, because he has no idea which transcriptionist is getting his dictation. I told my supervisor about that too. He has not done it since.
We are not allowed to keep any patient sm
records on our computers, at all. They should be stored in the provider's files if they want to keep them for access.
The patient's status
I got one yesterday that the patient's status currently is deceased. Wonder if that status is going to change in the future.
Patient list.
I too get a faxed list. However, the physicians use the list first and mark the patients they have dictated on. Then I check off as I transcribe. They do not ask for the list back, but if I notice any that the physician has marked that I did not transcribe, I let them know. In my experience doctors usually swear that they dictated the note and tend to get upset if they have to redictate later. I have worked inhouse in medical records so I also know how frustrating it is when a note is missing. The tendency is usually to blame the Transcriptionist if a note is missing, so it is nice to have that list if something comes up. However, at this office a staff member there goes through and double checks to make sure that the dictation is there. It all makes for a good relationship with the client in my opinion.
Some places use the SS# as the patient ID #. (nm)
.
It might not be fair to the patient, but --sm
sometimes these referrals need authorization from the insurance company and those are never fast. Pain clinics are also booked up probably a month or so in advance with other patients, as well. I really do not think they are delaying care on purpose, just that sometimes these things take time. I know it is hard to be patient when one is in pain. maybe you could perhaps suggest a different pain physician who may not be quite so busy??
This patient with a history of
Aids is status post Pneumocystis carinii pneumonia.
Old patient records
Does anyone know when you no longer have an account what do you do with the old records. Can they be deleted because they are no longer your account or do you have to save them in case the account ever needs them? All their notes over the years have either been printed and delivered or emailed to them and I don't keep them past a year.
Patient doing/during dictation
This just really annoys me! I can understand why busy doctors feel the need to dictate while they are with patients, but still, it is very annoying!!! I dictate for a pediatric neurologist, who is a wonderful dictator himself, very easy to understand. BUT, he dictates during the office visit and sometimes the patients are talking at the same time he is, does he stop the tape NO, does he repeat what he just said NO and then changes what he is saying sometimes based on their comments. Some of these children are very young, very disruptive, and very LOUD. He will also have the parents dictate their address sometimes, do they spell their crazy sounding roads NO. ARRRRGH. Anyone else have this problem or am I just having a hormonal day?
I guess I should just be thankful he doesn't take me to the bathroom with him any more often than he does!!! (and YES he does!)
dictating while seeing a patient
I must be weird because I never had a problem with the doctor dictating while seeing his patients. I worked in a busy clinic where one of the doctors pumped her breasts while dictating, one would eat hard candy and comment about the patients under his breath, one would tell dumb jokes in the middle of his dictations. We (the transcriptionists) got even with them one year at Christmas by publishing a little booklet of all their bloopers. We even got our raises that year!!!
Old patient records
When I closed up my accounts, I always gave the reports I saved on CDs back to the clinics. After all, I didn't need them any longer.
Patient's names
Especially when the name has a funny spellling and I keep going back to the header to see how to spell it!!
OP SAID the patient was not ESL, the doc was. READ.
d
Patient may ammend
A patient has the right to ammend a medical report if they so choose. I agree that we have to type what they say.
This will be seen by more people than just the transcriptionist, doctor and patient; however, as the coder will see it, chart auditors will see it, medical secretaries compiling charts will see it and the list goes on. I work in a hospital as well as at home and the report will always being in the chart. If that patient comes to the ER again, the next ER doctor and the nurses caring for that patient will probably see the report. Insurance companies can have a copy of the report if they need it.
HIPPA does not mean total and complete confidentiality. Alot of people think HIPPA has made the chart more private than it used to be. It is a "portability act." That makes it easier for insurance companies and other people caring for the patient to gain access to those records. Just my 2 cents.
I am pretty sure that if the patient was not
religious prayer would not have been initiated and therefore would not have been mentioned. However, there is nothing "wrong" with mentioning it in a medical report.
I once had a doctor who described the patient as a "land whale." I transcribed it and then flagged it for my supervisor. She said, "appropriate or not, that is what he dictated so that is what we transcribe." She did refer it to him though.
cursing towards the patient
he was cursing towards the patient, something to the effect of "this 23-year old white female, gravida 6, para 2, ab 4 is F____ pregnant again". Also, I have had the same doctor call a patient a 'fat hog' before too..... so this is not something Ive not heard before from him. if it was cursing at the computer or something like that, i wouldn't even question it.......
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.
We are not allowed to put the patient's
name in a record and only "the patient" if dictated.
Jane Doe is not a patient name.
x
Patient confidentiality
I remember when I first started out in MT in a hospital part of medical records confidentiality agreement was that we only had access to records on an as needed basis and were not to be talking to anyone about the things we transcribed even if it was a relative, family member, etc. That was gee now close to 10 years ago.
I know like others on the board, it would be nice to know what EMR will mean for all of us. If we are to be out of jobs, I would sure like to know now so that I can start planning financially. Also, as I have been searching for more information on implementation of EMRs, the more I get concerned myself about my personal information possibly being spread. Given my still rather young age of 31 and having no medical conditions requiring medical attention/medication, it really makes me wonder if I may want to look more into alternative medical care or a private physician who has alternative medicine in addition to medicine as we currently know it.
The patient must be a child of
Bambi and Rambo!
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