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I would check your account specifics...(nm)

Posted By: Cathy on 2008-04-16
In Reply to: Code status - nm

Subject: I would check your account specifics...(nm)




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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.
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
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.
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.
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
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.


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.
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.


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. 


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


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.


OB.. she returns for a string check?? or Estring check?? Thanks
Subject: OB.. she returns for a string check?? or Estring check?? Thanks


...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
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


account?
Subject: account?

NM
On the account I'm on they want us to
Subject: On the account I'm on they want us to

type out potassium chloride. Which I'm only too happy to do with a shortcut, LOL.


The account that I am on
Subject: The account that I am on

The account I type is "almost verbatim".  We type subcu, but in the lab values we have to expand the workds (alkaline phosphatase, et cetera).  If a word is dictated that is not a known abbreviation, we have to type it out.  I think each account is different, and as the other poster said, they should have given you an client form so that you would know what the hospital expects. Sounds like your guy kinda got his tail in a crack and felt like he needed to unload on a poor, innocent MT who was just trying to do her job!  Hang in there!      W'e're cheering for you!


 


g is okay per BOS, but I have an account
Subject: g is okay per BOS, but I have an account

where the client profile forbids it and it must be written out as grams. Maybe yours is account specific too.
I am on a new account and need some help here.
Subject: I am on a new account and need some help here.

Patient has a mild s/l list to the left.  This is orthopedic.  I have postural list in my Stedman's Ortho book.  Could that be it? 


New account for me/sm
Subject: New account for me/sm

All I know is baby had Norwood procedure on her heart.  Is it some sort of monitor?
Does your account use the BOS 2?
Subject: Does your account use the BOS 2?

That's the source of the "Don't capitalize it when it stands alone" rule. My suggestion would be to follow BOS if your account uses that and to be consistent. Stedman's is (are?) notorious for inconsistency with this sort of thing.
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?


If you expand it (and you should if your account allows), sm
Subject: If you expand it (and you should if your account allows), sm

it should be "cardiac catheterization," not "cardiac catheter." 
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!
Ask your QA what the account prefers. If it's sm
Subject: Ask your QA what the account prefers. If it's sm

verbatim, I would use T-max if that's what was actually dictated.

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.
Thanks. Didn't know it. New account (nm)
Subject: Thanks. Didn't know it. New account (nm)


You might want to see if you can get this clarified for your account since
Subject: You might want to see if you can get this clarified for your account since

there is a product called ZAP and I don't know what your doc was using it for. :-)
What abbreviations are and are not appropriate will be different for each account sm
Subject: What abbreviations are and are not appropriate will be different for each account sm

Go with what your QA tells you.  It may be acceptable but the doctor may not like/want it done that way.  I've found every account has different rules and preferences.
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. 
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.
ONLY if your QA, account, or docs want it to be so. Not everyone
Subject: ONLY if your QA, account, or docs want it to be so. Not everyone

s
Of course you first and foremost do what your account wants sm
Subject: Of course you first and foremost do what your account wants sm

and as I said, that is how I was taught.  Now, every account I've done wants it that way and it is that way on the Dangerous Abbreviation list...AND that's what I said - use mL not cc.