Account specifics would dictate whether you sm
Posted By: CL on 2006-01-05
In Reply to: ekg shows paced rhythm at 76 beats per minute, sm - Jelly Bean
Subject: Account specifics would dictate whether you sm
write it out or abbreviate. The abbreviation for beats per minute is bpm. Ask your QA person for approved abbreviations for this account (accounts will differ sometimes which can make us crazy).
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That's what I mean by "ask your QA!" Account specifics dictate style, sm
Subject: That's what I mean by "ask your QA!" Account specifics dictate style, sm
but the AAMT BOS dictates what is correct for the industry, getting its information from sources such as the Chicago Manual of Style, the American Medical Association book of style (which I own), etc. As the poster below states, Joint Commission goes by BOS and does not like "same" or abbreviations for diagnoses, impressions, op titles, etc. They will randomly choose patient charts and go through them to check things like this! It's the Joint Commission which recommends or removes hospital accreditations--a very powerful entity.
So, ask your QA what the account wants. If they want "same," give them "same." For other accounts, do it the correct way.
account specifics for that particular account should state how it is to be typed. nm
Subject: account specifics for that particular account should state how it is to be typed. nm
.
Also, don't know about your account specifics but
Subject: Also, don't know about your account specifics but
I would use 1.5 cm, as in 1.5-cm "hypoechoic" mass...decimals for metric...
Account specifics - if they want 's that's what they get. SM
Subject: Account specifics - if they want 's that's what they get. SM
That's what is in AAMT BOS - Depends on client preference, so, no, she is not wrong
All according to your account specifics. Like
Subject: All according to your account specifics. Like
I said below, we do not use slang, therefore use saturating; however if verbatim, then satting is correct.
What do your account specifics say? nm
Subject: What do your account specifics say? nm
nm
do you have account specifics to read?
Subject: do you have account specifics to read?
on most accounts it is acceptable to leave 1-2 blanks. If you really think it sounds like minute, then put that.
Depends on account specifics. sm
Subject: Depends on account specifics. sm
In general, we are to write out the term in full the first time it is dictated for clarification. Then, if abbreviations are dictated later on, it is okay to use the abbreviation. Again, you must abide by account specifics. Ask your QA person to be sure.
also I should have said check your account specifics - SM
Subject: also I should have said check your account specifics - SM
Each doc and/or hospital may want classes and grades a certain way. It is a good idea to make sticky notes like Another KSMT said.
same here - depends on my account specifics nm
Subject: same here - depends on my account specifics nm
I would check your account specifics...(nm)
Subject: I would check your account specifics...(nm)
Almost depends on account specifics
Subject: Almost depends on account specifics
Some of the verbatim accounts allow for medical jargon, so if in the body of the report they said he was given 2 amps of bicarb, I would probably just leave it at amps. If this was in a medication list, as on admission or discharge, I would probably write it out as ampule(s).
depends on account specifics, whether verbatim, etc.
Subject: depends on account specifics, whether verbatim, etc.
x
First, see your account specifics or client preferences.
Subject: First, see your account specifics or client preferences.
If no mention is made about it, I would type it as a numeral for anything less than 10.
Although I would double check your account specifics. SM.
Subject: Although I would double check your account specifics. SM.
Some docs might prefer you to spell it out for them or have an specific way they want it typed.
check your company's Account Specifics, if you can
Subject: check your company's Account Specifics, if you can
nm
depends on account specifics, but I usually type 3-1/2 months NM
Subject: depends on account specifics, but I usually type 3-1/2 months NM
Got it. Thanks again. There are no account specifics, so I like to type verbatim just to be safe.
Subject: Got it. Thanks again. There are no account specifics, so I like to type verbatim just to be safe.
It all depends on your account specifics. If they use BOS, then use mL. I've had verbatim accou
Subject: It all depends on your account specifics. If they use BOS, then use mL. I've had verbatim accounts
with no BOS wanted per the client, regular accounts who do use BOS and others that do not want it, and others that "just type what I say." So, like I said, refer to your account specifics.
Always go with account specifics, regardless of what BOS recommends. Good luck! (no message)
Subject: Always go with account specifics, regardless of what BOS recommends. Good luck! (no message)
X
Depends on your account specifics. If they allow you to expand, that's fine, but it is straight
Subject: Depends on your account specifics. If they allow you to expand, that's fine, but it is straight
hardcore verbatim you have to leave it as is, whether it looks ugly or not. I know, I really don't like it when they abbreviate left and right, leave words off sentence structures so they can speak faster and get it over with.
Both are correct, just type it according to your account specifics, some like disc and other disk.
Subject: Both are correct, just type it according to your account specifics, some like disc and other disk.
Depends on the account: My verbatim account is VERBATIM and other accounts I put 3100
Subject: Depends on the account: My verbatim account is VERBATIM and other accounts I put 3100
You should dictate what the doc says.
Subject: You should dictate what the doc says.
If he is wrong, that's his problem. You can't just go changing what he says unless you have free reign on your account.
Drs get what they dictate - some of us only do..S/M
Subject: Drs get what they dictate - some of us only do..S/M
brachioplexus, brachioplexopathy - what they say is what they get....client profile RULES!
How does he dictate it? Is he actually - sm
Subject: How does he dictate it? Is he actually - sm
Is he saying "CBC, MSP, and stool" because stool is not a test so just wondering if it could be the name of a stool test. If you state just how the whole sentence is dictated, it may help us figure it out for ya.
I had a doc used to dictate that
Subject: I had a doc used to dictate that
Good says it stands for keep-open-vein. So, it should fit, and it also is all CAPs. 
More specifics?
Subject: More specifics?
Is it a myringotomy and tube insertion? Is it being pronounced bog or b-o-g?
Usually if they dictate Seldinger...
Subject: Usually if they dictate Seldinger...
they will say "via Seldinger, or Seldinger technique." I don't believe they would do this en route either. Are you sure you are hearing "sandwich?" I have been transcribing ER reports for years and I have never heard this term used. Anyway, I would not guess on this one. IMO, it is better to leave it blank and have QA inform you later so you can keep it on file .
Do it per client specifics.
Subject: Do it per client specifics.
Yes, that was how I was taught and most always they dictate cc nm
Subject: Yes, that was how I was taught and most always they dictate cc nm
nm
welcome; got it from my docs that dictate it as i never could figure them all out either, lol. nm
;
Sorry, but I have had them dictate brain or beta.
Subject: Sorry, but I have had them dictate brain or beta.
nm
Did she dictate the colon after "murmur?" nm
Subject: Did she dictate the colon after "murmur?" nm
x
no matter what they dictate, they are wrong...nm
Subject: no matter what they dictate, they are wrong...nm
...in the client specifics very clearly. Otherwise, QA should let it slide. nm
Subject: ...in the client specifics very clearly. Otherwise, QA should let it slide. nm
s
LOL..the way these docs dictate anymore
Subject: LOL..the way these docs dictate anymore
who knows!! Something like that just check your aspirin bottle. Good luck!!
Check with your TL on the specifics of the facility.
Subject: Check with your TL on the specifics of the facility.
Most hospitals I have worked with prefer cm2.
doctor didn't dictate mg????
Subject: doctor didn't dictate mg????
The patient was given aminophylline, Lanoxin 0.25, Lasix 40 mg, Cardizem.
okay here the doctor fails to dictate mg? according to 'textbook rules' do I add this or not?
Lordy, when they dictate commas it is just sm
Subject: Lordy, when they dictate commas it is just sm
like a poke in the eye to me!!! Brings me to a screeching halt. I just tend to ignore them, in a report, especially if it is a resident. I do puncturate letters and memos, but half the commas I see people use on this board and other boards are totally not necessary. Just call me
anti-comma!!!!!
If you dictate the full sentence I could probably help you figure it out. nm
Subject: If you dictate the full sentence I could probably help you figure it out. nm
Thanks for finding that. I just had doc today dictate this...hmmmm
Subject: Thanks for finding that. I just had doc today dictate this...hmmmm
doc didn't dictate that....her brain was thinking that...
Subject: doc didn't dictate that....her brain was thinking that...
nm
Thought so thanks wish they would dictate the drugs correctly
Subject: Thought so thanks wish they would dictate the drugs correctly
or may be mistakenly thinking of their pet's food as they dictate?
Subject: or may be mistakenly thinking of their pet's food as they dictate?
wrong - they ALL dictate decubiti...no such word
Subject: wrong - they ALL dictate decubiti...no such word
did he dictate the point, or did he say 1 5, to make sure you did not hear 50
Subject: did he dictate the point, or did he say 1 5, to make sure you did not hear 50
nm
yes, but without specifics it's impossible to know if you're hearing it right
Subject: yes, but without specifics it's impossible to know if you're hearing it right
Derm docs often dictate "Allergy to CARBO mix" - sm
Subject: Derm docs often dictate "Allergy to CARBO mix" - sm
I don't know what the full word is, but this validates your hearing the partial "carbo"
Long shot, but often dictate myocardial ischemia. nm
Subject: Long shot, but often dictate myocardial ischemia. nm
xx
Macrobid (nitrofurantoin) is commonly used, maybe doc stumbling on whether to dictate brand name or
Subject: Macrobid (nitrofurantoin) is commonly used, maybe doc stumbling on whether to dictate brand name or generic?
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