Depend if the doctor says it and it is a verbatim acct.
Posted By: depends. on 2007-01-11
In Reply to: Gestational age - 35 weeks 1 day - never a comma or "and" Correct? - QA question
Subject: Depend if the doctor says it and it is a verbatim acct.
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verbatim acct help
Subject: verbatim acct help
General surgeon talking about frozen section pathologic exam of squamous cell carcinoma lesion. First frozen section came back with positive margins so he went back to excise a second specimen which he submitted S/L "on fos" with the new margin up. This is a verbatim account and this dictator is on 100% QA (all reports) since he is so SPECIAL. I referenced the other reports in his MD data base and found "en Fos" which would have been put there by QA before the report was signed off to the hospital. I can't find this anywhere and was wondering if anybody has a clue?
my main acct is verbatim,
Subject: my main acct is verbatim,
and we are told we can change sentence structure...however, whether i'm told that or not, i correct to proper English, including tenses, etc. Verbatim is never really absolutely verbatim, no matter what anyone says. You must use common sense. The bottom line is to be careful that you never change the intended meaning.
depends on whether or not it's a verbatim acct
Subject: depends on whether or not it's a verbatim acct
depends, is it verbatim acct? If not, change it to
Subject: depends, is it verbatim acct? If not, change it to
I would, but I'm a rebel. Check acct. specs re verbatim. n/m
Subject: I would, but I'm a rebel. Check acct. specs re verbatim. n/m
Thank you. This particular doctor isn't verbatim so I'll use that! :)
Subject: Thank you. This particular doctor isn't verbatim so I'll use that! :)
Type it exactly as the doctor dictates, verbatim....nm
Subject: Type it exactly as the doctor dictates, verbatim....nm
nm
Once again, just me, but if it is not verbatim I would type out hematocrit, if verbatim "give it
Subject: Once again, just me, but if it is not verbatim I would type out hematocrit, if verbatim "give it to them".
verbatim is VERBATIM....bad advice he gave you.....
Subject: verbatim is VERBATIM....bad advice he gave you.....
Would depend on what they are doing?
Subject: Would depend on what they are doing?
That would depend on what the
Subject: That would depend on what the
normal said. For example, if it says "breasts are soft and pendulous", you might want to leave that out. Men generally don't have pendulous breasts, not even ones with gynecomastia. If it simply refers to the fact that there are no masses or nipple discharge, I would probably leave it in.
If you're still unsure, you can always flag it and find out for future reference.
New acct: SM
Subject: New acct: SM
Okay, been away from transcribing general practice for while. Dictator is running a marathon here. I have a couple of questions.
Patient is s/l attentionly and alert plus and cooperative.
for the life of me I am not hearing what I want to hear...awake, alert, oriented times three. etc.
Also, in PE: Lymphatic system s/l neither anterior and posterior cervical chain.
might depend on client
Subject: might depend on client
I have been using weightbear and weightbearing for the past two years and neither the QA or the client have every complained or requested otherwise. matter of opinion, I guess.
It may depend on the account, but I think most
Subject: It may depend on the account, but I think most
people add dosage. The doctor is only one of many people who read the chart.
I think it would depend on the drug....
Subject: I think it would depend on the drug....
??
New doc, new acct, ideas?
Subject: New doc, new acct, ideas?
Does this sentence make sense to any of you? This is a disability and he it sounds like he is saying jaw? but why would that be under cardiorespiratory?
CARDIO-RESPIRATORY: He has no signs of cardiac abnormalities, no claudication, no chest pain, or numbness of the jaw.
Could it be something else? Please give it a try!
it would depend on what type of an account you are
Subject: it would depend on what type of an account you are
working on. and your company specifics. if its verbatem..then you put the word "hour" whenever the dictator dictates it. if he just says something like "time seen...0600 hours" then:
TIME SEEN:
0600 hours.
yes, me too - also it may depend on client preference NM
Subject: yes, me too - also it may depend on client preference NM
it may depend on a facility rule
Subject: it may depend on a facility rule
our facility requires a hyphen for any statement of __ to__ so for us it would "x4-5" days.
That's okay...I have days like that myself and I can always depend on help from my fellow MTs. nm
Subject: That's okay...I have days like that myself and I can always depend on help from my fellow MTs. nm
nm
New GI acct. Does anyone have any helpful links? TIA
Subject: New GI acct. Does anyone have any helpful links? TIA
Right.....it depends on the acct.....mine wants the "c"
Subject: Right.....it depends on the acct.....mine wants the "c"
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Only if your acct wants it changed. Not KS here, but our docs
Subject: Only if your acct wants it changed. Not KS here, but our docs
s
Thx. I am helping on new acct for holidays, and not doing too well :(
Subject: Thx. I am helping on new acct for holidays, and not doing too well :(
Depends on your acct specs. nm
Subject: Depends on your acct specs. nm
s
Would depend on the context. In the office setting, it could be. I don't
Subject: Would depend on the context. In the office setting, it could be. I don't
s
Would depend on your account and whether they allow headings where necessary or not. If heading is w
Subject: Would depend on your account and whether they allow headings where necessary or not. If heading is warranted, I would use CLOSURE.
pin ... does your acct require you to adhere to dangerous
Subject: pin ... does your acct require you to adhere to dangerous
just asking
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
typing med list and thru the mumbling s/l FILLA-DEPEND ER 5 mg. nm
Subject: typing med list and thru the mumbling s/l FILLA-DEPEND ER 5 mg. nm
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It would depend on your client profile for that account. I have never run across numbers within the
Subject: It would depend on your client profile for that account. I have never run across numbers within the axes, it would normally just be commas between each diagnosis or periods if that is what the client calls for. Check with that CP if you can.
I always use combined forms ie. posterolateral, but would depend on your account i suppose. nm
Subject: I always use combined forms ie. posterolateral, but would depend on your account i suppose. nm
no,not verbatim. if it were, i would type it verbatim. nm
Subject: no,not verbatim. if it were, i would type it verbatim. nm
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If it is verbatim, then type it verbatim.
Subject: If it is verbatim, then type it verbatim.
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s/l neruo forminal is this correct ? Sorry started a new acct today and unsure if one word or two.
Subject: s/l neruo forminal is this correct ? Sorry started a new acct today and unsure if one word or two.
x
Muffin is correct. My children's hosp. acct uses McMuffin & muffin nm
Subject: Muffin is correct. My children's hosp. acct uses McMuffin & muffin nm
nm
Verbatim
Subject: Verbatim
My primary acct is a verbatim but am allowed to make grammatical corrections as long as it does not change the meaning. One of my docs dictated *monna releaser*. After getting my laugh for the day, I typed *I am going to release her*....this one was not an ESL. Gotta getta good laugh once in a while to keep sanity....
No, it is not verbatim...
Subject: No, it is not verbatim...
I think I have come to that conclusion, also. There is just too much for me to try to fix it all. I'm not sure I would even know where to begin. There is just so much garbage... Thanks for verifying my thoughts, though.... :)
Verbatim - is it tib/fib or tib-fib ???
Subject: Verbatim - is it tib/fib or tib-fib ???
verbatim or not?
Subject: verbatim or not?
verbatim
Subject: verbatim
is it verbatim?
Subject: is it verbatim?
if its a verbatim acc...sm
Subject: if its a verbatim acc...sm
then you must write what you hear, if not, its up to you.
Verbatim - hep c.
Subject: Verbatim - hep c.
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verbatim help
Subject: verbatim help
hi, i need help with a verbatim account. if they say "two PM" can i type 2 PM? or should i type 2:00 PM? and for dates, if they say "o eight," can i still type 2008?
yes, there should be, unless verbatim
Subject: yes, there should be, unless verbatim
xx
Verbatim 3/10 cc or 0.3?
Subject: Verbatim 3/10 cc or 0.3?
Would this be actual "verbatim" transcription or correct, per BOS? What would vertaim be when you have to type exactly what they say even if it is not proper? I think that is what the OP was asking. Now I am curious.
In verbatim account... HELP PLEASE
She is sating(satting) 98% on room air?
I want to change, but on verbatim, I suppose I'm not supposed to, right? I'm relatively new to this and not sure.
Verbatim account
Subject: Verbatim account
How would you type... as I have it?
ESL help..with verbatim account..
Subject: ESL help..with verbatim account..
would you type re-meet? remeet? or change to meet again... It is vebatim, but I'm not used to that yet... need seasoned advice! Thanks!
I would write it out even if it is verbatim
Subject: I would write it out even if it is verbatim
PPD is a test for tuberculosis. You aren't just writing a document to appease the doctor. You are writing a legal document that many other people may want to read, including an insurance auditor or a lawyer, neither of which may have any clue what PPD means EVEN IN THE CONTEXT OF THE SENTENCE and will have no inclination to look it up.
That's just me, someone who audits physician records and slaps them on the wrists for this like this, but you do want you want.
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