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I am on a verbatim account so I have to type it either way it is dictated L4-L5 or L4-5. As far OB/G

Posted By: MT50 on 2008-02-15
In Reply to: Ortho and OB-GYN questions - wondering

Subject: I am on a verbatim account so I have to type it either way it is dictated L4-L5 or L4-5. As far OB/GYN, G2, P3 or gravida 2, para 3 means with the 3-0-0-2: 3 live births, 0 preterm births, 0 miscarriages, 2 living children




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If you are on a verbatim account, type exactly what is dictated.
Subject: If you are on a verbatim account, type exactly what is dictated.

If you sense a discrepancy, you can flag it for your QA department.
I would leave it as dictated, esp if verbatim account. nm
Subject: I would leave it as dictated, esp if verbatim account. nm

x
That's the way I type it when the account is verbatim. Otherwise, you could correct to incised an
Subject: That's the way I type it when the account is verbatim. Otherwise, you could correct to incised and


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.


type "the year" if it is a verbatim account.
Subject: type "the year" if it is a verbatim account.


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


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!
On a verbatim account, would you
Subject: On a verbatim account, would you

actually leave this sentence as is?


She puts Neosporin on it, and she reports that in the morning it looks pussy.  


 TIA for any input.


Only if the account is verbatim would I
Subject: Only if the account is verbatim would I

type 5 foot. Should be 5 feet.
It is a verbatim account so I can't add the bag ;) sm
Subject: It is a verbatim account so I can't add the bag ;) sm

He just said the patient was *ambued and could not be intibated due to facial trauma* 


So, looks like this is one of those that is up in the air and probably something to talk to company QA about? 


 


Is this a verbatim account?
Subject: Is this a verbatim account?

If not, it would make more sense like this:

It would help beneficial organisms AND commensals bacteria colonize his colon and help as a first line of protection against disease.

If not, then I would type:
It would help beneficial organisms, commensals bacteria colonozie his colon and help as a first line of protection against disease.

Since they want the beneficial bacteria and commensals bacteria to colonize his colon, there is no need for a comma before colonize.
If the account is verbatim, I would say OK
Subject: If the account is verbatim, I would say OK


I use it only if my account is verbatim.
Subject: I use it only if my account is verbatim.


If you are on a verbatim account it could be 4, 80 and 0.
Subject: If you are on a verbatim account it could be 4, 80 and 0.


Verbatim account?
Subject: Verbatim account?

Valsalva maneuver.  Lots of docs turn it into a verb, so I would say if it is verbatim, what you have is how to spell it, all lower case.
Unless its a verbatim account
Subject: Unless its a verbatim account

I rearrange the sentence so that it is not the beginning. If it is a verbatim account you don't want to change anything but type as both letters in caps, PH.
if verbatim account yes sm
Subject: if verbatim account yes sm

It depends on the client profile. On my non-verbatim accounts, I leave out the is and are in the vitals signs and for allergies, I just type the Demerol and Penicillin under the heading. That's just how I've been doing it for over 15 years and so far so good :)
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 account, doc said "pee"
Subject: Verbatim account, doc said "pee"

Should I edit to "urinate" or type as is? If as is, should I put it in quotes?


Diagnosis is micturation syncope. Here is the sentence as dictated:


When he tried to pee he got weak, dizzy, hit the floor, did not feel right.


 Thanks for any help.


I'd leave it, especially if it's a verbatim account.
Subject: I'd leave it, especially if it's a verbatim account.

nm
Are you typing on a verbatim account?
Subject: Are you typing on a verbatim account?

If so, you will won't need to change decease to deceased. If the dictator is ESL, he probably used incorrect verbiage. Agree with other posters about lung CA.
Are you a verbatim account? Because I would rather put "undetectable" as well.
Subject: Are you a verbatim account? Because I would rather put "undetectable" as well.

nm
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.


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.
Same here, but now my account is verbatim so I give em what they ask for.
Subject: Same here, but now my account is verbatim so I give em what they ask for.


The second one is correct if account is verbatim; never
Subject: The second one is correct if account is verbatim; never


If not verbatim account and you are allowed
Subject: If not verbatim account and you are allowed

to add headings, I would put it under either MUSCULOSKELETAL or NEUROLOGIC.
depends on account specifics, whether verbatim, etc.
Subject: depends on account specifics, whether verbatim, etc.

x
Thanks...that option is not allowed as my account is verbatim...
Subject: Thanks...that option is not allowed as my account is verbatim...

I put the word in as dictated with quotes around it and then sent it off to QA. I noticed later that they just deleted it and put a blank and sent it through without the word. Yet one more reason why I hate being on verbatim accounts!
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....


Good question, is this a verbatim account? SM
Subject: Good question, is this a verbatim account? SM

If not, I guess para-colposcopic, para-cervical maybe?
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.


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.
yeah, if you're a verbatim account do nitro paste, otherwise
Subject: yeah, if you're a verbatim account do nitro paste, otherwise

spell out to nitroglycerin paste. Doc slang. Don't cha love it!
If verbatim then that is correct. If you have to expand (as in my account) it is maximum temperature
Subject: If verbatim then that is correct. If you have to expand (as in my account) it is maximum temperature. (nm)

x
Personally, I do a verbatim account and I have begun sentences with "CT".
Subject: Personally, I do a verbatim account and I have begun sentences with "CT".


alk phos is slang, fine if verbatim account, otherwise spell it out. nm
Subject: alk phos is slang, fine if verbatim account, otherwise spell it out. 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

zz
If it is verbatim, then type it verbatim.
Subject: If it is verbatim, then type it verbatim.

x
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 type it under PLAN and type what is dictated.
Subject: I would type it under PLAN and type what is dictated.

I have had that happen to me before, and I was told by QA to not move things around in the report, maybe that is the same for you, but if I were typing this report, I would type it in the order as is dictated, even if that means typing it under the heading PLAN.  Also, his vitals were probably taken at the end of the exam as they were repeated, so it would make sense to type them again under that heading.  Hope that helps! 
I would type it verbatim.
Subject: I would type it verbatim.


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


i would type as dictated.
Subject: i would type as dictated.

x
Type whatever he dictated.
Subject: Type whatever he dictated.

x
I'm with you, I type what is dictated. sm
Subject: I'm with you, I type what is dictated. sm

It is not my place to decide what the doctor means. I am not in any way offended by what he/she dictates.
You are correct, pus-like is not the same as pussy.
If they say the F word, I type the word, not asterisks in place of letters, because it's a direct quote from the patient. I do not change direct quotes.
Anybody who is offended by typing a word is putting way too much of their personal life into their work.
No, you type it as dictated.
Subject: No, you type it as dictated.