Changing what is dictated is not always appropriate
Posted By: They said what on 2008-11-28
In Reply to: I would type pus-like because... - Kendra
Subject: Changing what is dictated is not always appropriate
even if you are offended by profanity. If the doc you are transcribing has a quote in it, you have to type as dictated or it is not a quote. If the physician is using profanity that has nothing to do with what the patient actually said, then some clients require you to change the words, because it is inappropriate otherwise.
My stance on this is just this. If it is a quote, don't change it, because it changes the integrity of the document. Whether you are offended or not, these medical records also serve as legal documents. You must keep that in mind. Just because you are offended is not a reason to change the words.
Complete Discussion Below:  marks the location of current message within thread
The messages you are viewing
are archived/old.
To view latest messages and participate in discussions, select
the boards given in left menu
Other related messages found in our database
Just as you have it if that's what was dictated. If "one fourth" was dictated, sm
Subject: Just as you have it if that's what was dictated. If "one fourth" was dictated, sm
it would be 1/4 pill or one fourth of a pill.
Def an 'N' dictated - Diabetes unsure of - no PMH dictated
Subject: Def an 'N' dictated - Diabetes unsure of - no PMH dictated
she is changing her name in threads.....nm
Subject: she is changing her name in threads.....nm
things are changing sm
Subject: things are changing sm
for whose benefit? So the AAMT can profit from more book sales. 15 year MT here--never have and never will buy into AAMT.
Gotten versus changing to got
Subject: Gotten versus changing to got
How many out there think when the doctor says gotten increasing large that replacing got for gotten sure looks better. Does anyone know off hand if there is an official grammar rule here. I think it looks bad!
He may be changing his mind from 4 to 6 as in 24.6 or 24, 600? nm
Subject: He may be changing his mind from 4 to 6 as in 24.6 or 24, 600? nm
.
changing question
Subject: changing question
I guess my original question shoud be if I have 300 cc or more rather than just 1 cc, should it have an s behind it or or just read cc. I have been corrected to be just cc and for some reason I remember it should be apostrophe (cc's)
changing around doctors words
Subject: changing around doctors words
What is considered normal and appropriate.. if the doctor usually says things or an expressoin a certain way and this expression is on my autocorrect is it okay for me to type it in that way (with my autocorrect) if he changes around the sentence but it really means the same thing anyway. Also, how much is it acceptable to change what he says.
It should be mEq. I would feel confident in changing it.
Subject: It should be mEq. I would feel confident in changing it.
x
or changing the word "the" to "a" liner...
Subject: or changing the word "the" to "a" liner...
QA ended up changing it to "right" in chief complaint
Subject: QA ended up changing it to "right" in chief complaint
Times they are a changing. Mucopus is a legit word? nm
Subject: Times they are a changing. Mucopus is a legit word? nm
.
I type tonic-clonic a lot, and that's not there. So, no one has heard of clinical or changing sm
Subject: I type tonic-clonic a lot, and that's not there. So, no one has heard of clinical or changing sm
Clonic to clonical? Sigh.
We type it as dictated, if dictated
Subject: We type it as dictated, if dictated
c spine we transcribe C-spine, if cervical then cervical spine.
I would use saline since it's the solution he's changing from half-normal to normal, not the
Subject: I would use saline since it's the solution he's changing from half-normal to normal, not the
s
for PA- DICTATED BY PA's name...nm
Subject: for PA- DICTATED BY PA's name...nm
x
Dictated 427 rbc's and 58 rbc's
Subject: Dictated 427 rbc's and 58 rbc's
what was dictated; if not, do it your way...NM
Subject: what was dictated; if not, do it your way...NM
x
what was actually dictated?
Subject: what was actually dictated?
This was just also dictated under sm
Subject: This was just also dictated under sm
past surgical history, but STILL sounds like dragon pack. This is going to drive me nuts!!!!
exactly as dictated.
Subject: exactly as dictated.
x
L4-5 if that is what is dictated NM
Subject: L4-5 if that is what is dictated NM
xxx
Thanks! He only dictated one N
Subject: Thanks! He only dictated one N
Thank you!
If that is what he dictated, then that is
Subject: If that is what he dictated, then that is
what you use, even though it is usually esophagogastroduodenostomy; however, maybe duodenum has been removed so therefore could be.
Just like he dictated it.
Subject: Just like he dictated it.
x
Yes, as dictated. (nm)
Subject: Yes, as dictated. (nm)
.
I'm not sure if this is one or two drugs being dictated. SM
Subject: I'm not sure if this is one or two drugs being dictated. SM
I will refill her Armour Thyroid and her s/l modratic and estrace
or maybe it s/l modratic in estrace??? any clue what this is ???
do it, regardless if dictated differently...nm
Subject: do it, regardless if dictated differently...nm
x
Whichever way it was dictated. nm
Subject: Whichever way it was dictated. nm
x
it depends on how it is dictated...sm
Subject: it depends on how it is dictated...sm
6600 (no comma) or 6.6 if they say it that way; if they say 6.6 thousand then you give them *6.6 thousand*
give them what was dictated as the pt probably...nm
Subject: give them what was dictated as the pt probably...nm
It's okay. I'd transcribe it as dictated. nm
Subject: It's okay. I'd transcribe it as dictated. nm
/
You don't add in mg or mcg, etc. unless it's dictated. The docs know
Subject: You don't add in mg or mcg, etc. unless it's dictated. The docs know
s
lasered, as dictated
Subject: lasered, as dictated
.
SGOT dictated: 4-2-6 T: 426 or 4.26
Subject: SGOT dictated: 4-2-6 T: 426 or 4.26
SGOT dictated: 4-2-6 T: 426 or 4.26. same with SGPT dictated 1-1-9 T: 119 or 1.19
I have only used galactorrhea as dictated. nm
Subject: I have only used galactorrhea as dictated. nm
I don't think that would be it because the dr who dictated it is a urologist.
Subject: I don't think that would be it because the dr who dictated it is a urologist.
Earlier in the note, the dr said he did not get an s/l osbot or ozbot appt.
Complete hx not dictated
Subject: Complete hx not dictated
Thanks! Kept your info for future reference. Endo doc just dictated as part of hx; did not elaborate, so not sure.
Never heard it dictated but (sm)
Subject: Never heard it dictated but (sm)
I have heard of some hollistic remedies that include a clorox soak of the feet for yellow nails however normally the docs order Lamisil (terbafine hydrochloride). Just my two cents sorry I couldn't be more help.
five-way CABG if that is what he dictated. nm
Subject: five-way CABG if that is what he dictated. nm
xx
I use rule of 2-3 min. per dictated min. (nm)
Subject: I use rule of 2-3 min. per dictated min. (nm)
x
I always type it the way you have it if that's the way it's dictated. sm
Subject: I always type it the way you have it if that's the way it's dictated. sm
Of course, go by your account specifics. If you can change it, some do. I always just type what they say and it keeps me out of trouble. :)
I would just type as dictated. nm
Subject: I would just type as dictated. nm
That's all I can think of too, but the labs were not dictated.
Subject: That's all I can think of too, but the labs were not dictated.
It was most always dictated to me under abdomen.
Subject: It was most always dictated to me under abdomen.
Leave as dictated...sm
Subject: Leave as dictated...sm
I've seen them that high before. You might see transaminitis in the diagnosis or something like that.
No dosage dictated
Subject: No dosage dictated
He doesn't dictate a dosage. Only problems he had dictated were:
hematuria
benign positional vertigo
pancreatitis
Idiopathic thrombocytopenia purpura
I appreciate your help!
I would leave it as dictated,
Subject: I would leave it as dictated,
x
What was dictated just prior to that?
Subject: What was dictated just prior to that?
.
i would type as dictated.
Subject: i would type as dictated.
x
No - most likely means what he dictated. nm
Subject: No - most likely means what he dictated. nm
x
|
