Depends on account specifics. sm
Posted By: fn on 2007-08-13
In Reply to: Clarification - Hopital Course - leave abbreviations? - SG
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.
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same here - depends on my account specifics nm
Subject: same here - depends on my 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
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
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.
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.
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
Account specifics would dictate whether you sm
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).
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.
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.
I would check your account specifics...(nm)
Subject: I would check your account specifics...(nm)
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
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.
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.
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
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
Depends on your account. nm
Subject: Depends on your account. nm
nm
Depends on account
Subject: Depends on account
My previous company had us leave the names out unless they were pertinent to the patient's care such as a caretaker. I.e. Dictated: Patient's wife, Susan, stated that. Transcribed: Patient's wife stated that. I would ask your QA about that to be sure though.
yes, depends on account
Subject: yes, depends on account
don't just go with the dictator-client may not be happy about it and you'll get in trouble. ask supervisor
It depends on account....sm
Subject: It depends on account....sm
I have been specializing in OPs for several years, (done everything else!), and love it, but we have doctors (have a few hospitals), who will give related system diagnoses and went them in one paragraph form with commas, as you wrote. But then, I have others that specify everything numbered. According the BOS from long ago, in Ops when listing diffent diagnoses, number them, but our rule from our company (owned by an MD!) is that, if they dictate in paragraph form, write it so, and if they dictate "numbered diagnoses," then put in numbered list fashion. Does that make any sense to you? Do you have account specifics for this doctor?? 
Honestly, it depends on your account....
Subject: Honestly, it depends on your account....
If it is strictly verbatim, then yes.
Depends on the account contract. The TAT for sm
Subject: Depends on the account contract. The TAT for sm
the company will be longer than the TAT for the MT. In other words, the company may have 24 hours to get the report turned around, but when they give it to the MT, the MT may only have 2 hours. I've been accustomed to a 2-hour TAT with the nationals I've worked for.
Depends on whether the account is verbatim sm
Subject: Depends on whether the account is verbatim sm
Or how much they expect you to correct. I used to transcribe for a doctor who did the worst run-on sentences and sometimes I would rack my brains trying to figure out where to put punctuation without changing what she said (the account was verbatim except for obvious grammatical errors like subject-verb agreement). Finally I decided, if that's the way she wants to say it, that's what she is going to get. I just made sure that what she was saying made some reasonable kind of sense. She was also notorious for changing her mind half a dozen times in a single sentence, and for not reading her reports before approving them. She once dictated a hysterosalpingogram (test to see if the fallopian tubes are blocked) and let the following impression go out to the requesting physician:
IMPRESSION: Bilateral tubal pregnancy.
instead of
IMPRESSION: Bilateral tubal patency.
(No, I didn't type it!)
Depends if it is a verbatim account. You can do it the way you have it or if he actually used the wo
Subject: Depends if it is a verbatim account. You can do it the way you have it or if he actually used the word "as" 93 then it could be 100-7 as 93 or just minus equal signs. Depends on your client.
Again depends on account; don't think MQ ever uses the symbol. nm
Subject: Again depends on account; don't think MQ ever uses the symbol. nm
nm.
depends on whether your account is verbatim (sm)
Subject: depends on whether your account is verbatim (sm)
It's slangy, but depending on the account, I might or might not edit.
I guess it depends on your account. sm
Subject: I guess it depends on your account. sm
I have always typed it RBCs per high-power field.
Depends on whether the account requires verbatim sm
Subject: Depends on whether the account requires verbatim sm
If they don't, I would change the tense to whatever is the norm for that account or that doctor.
If they do require verbatim, I would type it verbatim but let the QA preson know that the doctor had shifted tenses.
But that's just me....
they are the same.My doc mostly says drawer. Maybe depends on your account preference
Subject: they are the same.My doc mostly says drawer. Maybe depends on your account preference
I use tib-fib, but I would say it depends on the account. Some verbatim accounts do not like abbrevi
Subject: I use tib-fib, but I would say it depends on the account. Some verbatim accounts do not like abbreviations, others want it strictly verbatim. The rest seems appropriate to me, but I would say it is dorsiflex the ankle.
More specifics?
Subject: More specifics?
Is it a myringotomy and tube insertion? Is it being pronounced bog or b-o-g?
Do it per client specifics.
Subject: Do it per client specifics.
...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
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.
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
Depends....
Subject: Depends....
I have an ortho doc that insists on using it the way the dictionary shows it, follow-up. He is not of old school, very young and a professor. Says it is his biggest pet peeve to see it ever used without the hyphen, and doesn't care much for BOS rules.
So, when in doubt, I do it exactly the way the dictator wants it no matter what I think.
think it depends on where you are...sm
Subject: think it depends on where you are...sm
like colour/color, theatre/theater, etc. i think "hiccups" is more common in usa.
Depends...sm
Subject: Depends...sm
It honestly depends on your employer's guidelines. Check with your Editor/QA staff. Sometimes there is just no way to make a doc make sense on paper without changing everything around and so it's easier just to really type verbatim; some docs only need a tweak here and there, so you really need to find out what 'verbatim' means as applied to the account you are working on.
Depends
Subject: Depends
One nurse's notes
Two (or more) nurses' notes
depends on the doc
Subject: depends on the doc
I worked for a chiropractor who wanted it disc but every other type of doc I've done wanted it disk
depends on how much.....
Subject: depends on how much.....
leeway you have. With the comma there, it looks strange. If you have to transcribe verbatim, I would put a hyphen....thus, * New patient - arm pain...* If you have more leeway you could make a sentence * This is a new patient with a chief complaint of arm pain *. If that is too much and looks like you are padding lines, then you could try just * New patient with arm pain *
depends on what it is...
Subject: depends on what it is...
a stroke could be evolving or completed....
Depends -- sm
Subject: Depends -- sm
I think it depends on the state where you want the information.
type for a hospital in Washington state, and they have a state licensure site with just about everything in the same site (i.e. physicians and physical therapists, nurses, etc. )
On the other hand, Arizona has only the doctors in its doctor database, and you have go to the Arizona physical therapist site to search for them.
Generally, when I first start typing a particular state, it takes a while to build up a set of search sites, but as I find them I add them to my favorites and then create a category for that state, so I don't have to search so much the next time.
Have a great day.
it depends
Subject: it depends
It depends on if it is modifying something.
The diameter of the wound is 1 cm.
There is a 2-cm length length discrepancy.
That's how I decide whether to hyphenate or not. On plural numbers, you can something tell if it should be hyphenated if it is said singular - i.e. six centimeters = 6 cm or six centimeter difference 6-cm difference
does that help?
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