operative report vs procedure

• operative report vs procedure - confused
  • An operation involves cutting, procedures do not. - x
  • operate is to perform surgery - - sm
    • op vs proc - confused
      • Ask your QA what the account considers procedures sm - nm

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What is the most popular or should I say proper way of setting up a heading for an operative report, order, spaces, tabs etc?  I know the doctor's way is always right but some doctors do not give enough information and some give too much.  Just wondering if you tab over diagnosis and align or place list under headings.  And spaces after each heading.

DATE OF PROCEDURE:

PREOPERATIVE DIAGNOSIS:

POSTOPERATIVE DIAGNOSIS:

PROCEDURE PERFORMED:

SURGEON:

ASSISTANT:

COMPLICATIONS:

ESTIMATED BLOOD LOSS:

FINDINGS:

PROCEDURE IN DETAIL: 

Has anyone heard anything about this CD?  I found it on ebay.  It has over 1000 multispecialty operative sample reports.  It's called: Softext Medical Transcription CD of Report Samples.   eBay Listing: 180302333955. 

Sounds like it could be a really good reference.  Just wondering.

MT

Hi everyone, I was wondering if anyone knew of any good websites for medical equipment and/or websites to help with Op notes.  Much appreciated!! 

We all know they should, but my point was most won't. But then again, I do remember instances where it was addressed with some of the worst ones, and they improved for a while and back to the same thing.  One radiologist everybody hated typing had a very thick Latin accent, and I ran into him on the elevator and he asked me if I type his dictation, to which I replied in the affirmative, and he said, "Good luck to you, brave lady"!!!!!  Then he would have the audacity to complain to our supervisor that we left too many blanks, that he says the same thing every time, why do we leave blanks!  The nerve!  She did tell him that he was difficult to understand, but do you think he changed?  No.  One of the reasons we could not understand a lot is because he would turn the x-ray films as he was dictating, which would be very noisy, and then he would have the machine on speaker and turn his head from side to side as he'd dictate.  Nice!  But did he stop after being told this?  No.  Nuf said, really.  Just one tiny example. 

Please post a response

I have an account who asked me to provide them with a form that could use for standard outpatient procedure notes.  I personally feel that there are too many variations for them to use one paper form and offered for me to do it for them at a discount since almost the entire thing would be a standard that I don't have to type in its entirety.  This account is a great account and I figured it isn't a big deal say to chage 25 cents instead of a $1 (example) for the form since I only have to type a couple letters to pull up the form and insert any changes.

I really don't know the easiest way to keep track of this discount or what amount to discount.  Any ideas?  I'd rather see me getting a small amount for doing the form then to get nothing for them using a paper form.  Plus, the account is newer to me and I thought it might look like a plus for me to offer them a discount and to make their life easier by not having to dictate the entire note.

Thoughts...ideas???  TIA

had better get that sucker typed before it gets out of ONE MINUTE TAT.

a live alligator swimming around the flood waters there in one area. The newscaster kept saying it was live and nobody would come out and was avoiding that area until it disappeared. It's probably waiting somewhere quietly for its next dinner to walk by.

Two of my accounts are in New Orleans and I have typed hundreds of patients with abscesses that tested positive for MRSA over the last few months. The way the city is now cannot be helping this at all. A few of the docs I do are automatically  treating for MRSA now w/o getting the culture report just because they've seen so many cases.

That would be real news there.

No, the woman bought a LOUIS VUITTON with the money she got

(debit card).

Hi, all:  I've been getting my own small clients here and there, and I've had a request for a proposal to radiology reports for a small radiology group.  Their current vendor is charging them by report, not line.  Anyone have any idea what to charge by report?  I've done some calculating with regard to average lines per report, and I'm thinking of offering to do it for $3 per report.  Any idea if this is too high or too low???  Any input is appreciated........

Working as an IC you should be charging $2 per report, that is what I charge my clients.  Good Luck!!!

I work at home for a service, but not as an IC.  I found work changed by having a temporary copy on file - then the QA changes/corrections - and then relistened and found changes made that affected the whole report, different medications, different procedures and PMH, etc.  Information that will probably one day go on to another physician that is incorrect and that I did not transcribe, but with my initials on the report.  Of course, I realize that once the physician signs it that the liability is on him, but it's just inconceivable that someone would do this.  I saw this happen one other time when I worked in house and one Transcriptionist didn't like another one and this was done in order to try and get the disliked employee fired.  However, it did not involve my work then.  I keep thinking that MTs all think ethically and with a legal obligation to the patient, but I know in reality that to some it is just a job.  I am tetering on talking to the company and/or the account manager, especially since I have everything in black and white - the first report - the QA corrections - the changes to the report after it came back to me, etc.  I'm just looking for some guidance on how to handle the situation.