If I did that with the psych account I transcribe for...sm
Posted By: Ellen on 2007-10-21
In Reply to: Possible risk management issue - piglet
Subject: If I did that with the psych account I transcribe for...sm
I would have to flag about 90% of the reports! Small community hospital with a lot of younger patients with schizophrenia, schizoaffective disorder, bipolar, manic depressive, etc. I agree with above poster, it is usually said in the context of a quote made by the patient. If the poster saying it, i.e. "this f------g phone isn't working," then it might be a good candidate for risk management! I will say, it keeps things interesting when you transcribe this type of account. BTW...I don't mean to make fun of the patients, these are young people who go off and on their medications and who are seriously mentally ill -- they go off their medications in an attempt to feel more "normal," and make remarkable turnarounds during their admissions. Just very sad situations usually.
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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
.
s/l *naw-vin* 10 mg bid (not Novolin or Darvon) - psych pt but may not be psych med - TIA - nm
Subject: s/l *naw-vin* 10 mg bid (not Novolin or Darvon) - psych pt but may not be psych med - TIA - nm
x
Psych note Axis III s/l VPS and neuropathy. No health history in the note. Only meds listed psych
Subject: Psych note Axis III s/l VPS and neuropathy. No health history in the note. Only meds listed psych
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
how do you transcribe this??
Subject: how do you transcribe this??
Doctor says * cardiac-wise the patient is doing well * OR * GI-wise he has had, blah blah blah blah...
I personally do not like the phrase * dash wise * The only way around it, seems to me, is to add a bunch more words like * as far as his cardiac condition is concerned * which does not sound like the dictator.
What do you do?
I would transcribe it as pus-like...nm
Subject: I would transcribe it as pus-like...nm
nm
I transcribe it like so..
Subject: I transcribe it like so..
Last, First, M.D. But, I why? I just do. I have never had a complaint. But, I'll transcribe Last, Reverend First (pastor), or Last, Sister First (nun).
need to know the right way to transcribe....
Subject: need to know the right way to transcribe....
the doctor says---discharge medications and patient is still on--- Do I type it like this? DISCHARGE MEDICATION AND PATIENT IS STILL ON: or do I leave all caps and headings out and start a new paragraph?
Thank you-Is that how I transcribe it
Subject: Thank you-Is that how I transcribe it
too?
Tib-fib, how to transcribe it? Thanks. NM
Subject: Tib-fib, how to transcribe it? Thanks. NM
That's how I transcribe it
Subject: That's how I transcribe it
How would you transcribe this?
Subject: How would you transcribe this?
I'm doing a report on a hip arthroplasty, and the doctor says the Secur-Fit shell was driven into place in approximately 4520 parameter based off the sciatic notch.
Is that 45 x 20 or 45-20 or just as I have it above? I'm stumped!
How would you transcribe this?
Subject: How would you transcribe this?
I have a doctor who keeps saying axillosubclavian brachiocephalic vein as if this is one vein he is referring to, but I think it has to be two, so how would you transcribe it when he lists the procedures performed as:
1. Right axillosubclavian brachiocephalic vein mechanical venous thrombectomy using the Trellis-8 device.
2. Right axillosubclavian brachiocephalic vein balloon angioplasty using a 10 mm x 4-cm long balloon followed by 6 mm x 4-cm long balloon followed by 7 mm x 4-cm long balloon.
3. Supervision and interpretation of fluoroscopy for performance of right axillosubclavian brachiocephalic vein mechanical thrombectomy, thrombolytic therapy and balloon angioplasty.
He doesn't pause between the words axillosubclavian and brachiocephalic vein. Should there be a dash between the two or the word and?
how would you transcribe this
Subject: how would you transcribe this
8 instances of property damage level 1, 27 episodes of major noncompliance,
I transcribe it as
Subject: I transcribe it as
bilateral eye, bilateral knee replacement.
Transcribe 5.3
Subject: Transcribe 5.3
nm
Here is how I always transcribe it (sm)
Subject: Here is how I always transcribe it (sm)
Gram stain and gram-negative/gram-positive.
I would transcribe it exactly as you have it. nm
Subject: I would transcribe it exactly as you have it. nm
.
If that is what he says, that is what you transcribe.
Subject: If that is what he says, that is what you transcribe.
x
How would you transcribe this? (SM)
Subject: How would you transcribe this? (SM)
"Sublingual nitroglycerin 0.4 mg "q.5's" p.r.n. for chest pain."
Is it okay to leave as is?
Yes, transcribe as 4.0 (sm)
Subject: Yes, transcribe as 4.0 (sm)
If dictated as "four point oh," you would transcribe as 4.0.
The zero after the decimal indicates the precision of the measurement. In lab values, you would need to transcribe as dictated in order to avoid "changing" the measure.
If you transcribed it as 4, the reader would wonder what you left off. A zero in other locations might be optional or up to the preference of the facility, but not this one.
how do you transcribe this?
Subject: how do you transcribe this?
We will need some ongoing p.r.n.'s of the MSIR.
gotten - when a doc says this, what do YOU transcribe?
Subject: gotten - when a doc says this, what do YOU transcribe?
That is how I transcribe it too.
Subject: That is how I transcribe it too.
We try not to use all caps even if the manufacturer uses all caps.
How do I transcribe this?
Subject: How do I transcribe this?
The patient will return in four weeks/weeks' time.
How would you transcribe this?
Subject: How would you transcribe this?
"The patietn is a 59-year-old who presented yesterday with shortness of breath and a hypertensive urgency of 120 over approximately 120 blood pressure."
Would the last part be "120/approximately 120 blood pressure" or just spell everything out like I have it?
TIA!
How would you transcribe this???
Subject: How would you transcribe this???
The doctor is saying that the wound was packed with 4 x 4s. Would you transcribe it as 4 x 4s or 4 x 4???? TIA
Can someone tell me the correct way to transcribe
Subject: Can someone tell me the correct way to transcribe
A fib. I learned in school that it's A-fib. I used to type for cardio docs on my own account, and they wanted A fib. Stedman's Abbrv. has AFib, and another book has A Fib. Is there a "correct" or most preferred way? Thanks.
I transcribe: 5- to 6-mm nodule. NM
Subject: I transcribe: 5- to 6-mm nodule. NM
d
CORRECT WAY TO TRANSCRIBE
Subject: CORRECT WAY TO TRANSCRIBE
pt developing increasing pulmonary pressures in the 60s and 70s - or 60's and 70's?
Also, if doc dictates calcium one every day, calcium one q.d. or calcium q.d.?
THANKS!!!
It's okay. I'd transcribe it as dictated. nm
Subject: It's okay. I'd transcribe it as dictated. nm
/
How do you transcribe this sentence?
Subject: How do you transcribe this sentence?
MRI scan has reportedly shown central herniation at C4, 5 and C5, 6
how do you transcribe q 6 h for a prescription?
Subject: how do you transcribe q 6 h for a prescription?
as in 1-2 p.o. (q 6 h) p.r.n. pain.
Omigosh - I think we transcribe for the same doc!
Subject: Omigosh - I think we transcribe for the same doc!
One doc I transcribe for just does his doctor "thing" to support his dog habit - breeding Labradors, training them for field trials, etc. And he has a habit of saying things backwards, like Tenmo needle for Temno needle and even things like humerotibial joint instead of femorotibial joint! 
how do I transcribe 10 to the 5th power?
in MS Word? Thanks
Do you transcribe 'teed' or 'T'd'
Subject: Do you transcribe 'teed' or 'T'd'
Hip replacement OP note:
"The posterior capsule was T'd and the head removed without difficulty."
I peeked in my Stedman's Ortho and on-line and cannot find a definitive answer to this. Thanks in advance if you can help!
transcribe like any other note. It was not necessary for you to
Subject: transcribe like any other note. It was not necessary for you to
nm
correct way to transcribe.....
Subject: correct way to transcribe.....
I know this is very basic, but what is the correct way to transcribe the dimensions of a wound - 12 x 15 cm or 12 by 15 cm, 12 cm x 15 cm, etc...?
You transcribe it as per your client's
Subject: You transcribe it as per your client's
wishes. If it is an obvious error I do correct. However, if it is a strict verbatim account, you transcribe it as dictated. Way back when, we were told to transcribe H&Ps and Consults in the present tense and DS & Ops in the past tense. However, with all the "new" rules and changes who knows anymore.
I always transcribe it just like you chose.
Subject: I always transcribe it just like you chose.
x
You transcribe what the doctor says. It is not
Subject: You transcribe what the doctor says. It is not
our job to change their words. If you are uncomfortable with it, type it and flag it for your supervisor to look into.
All of a sudden everyone on this board is questioning whether or not we type what the physician or dictator says. That is our job. He is responsible for the content, not us.
I transcribe it 3/4 portal. Anyone else? nm
Subject: I transcribe it 3/4 portal. Anyone else? nm
.
The BOS says transcribe it every evening. nm
Subject: The BOS says transcribe it every evening. nm
.
You transcribe what he/she dictates.
Subject: You transcribe what he/she dictates.
You transcribe the values as dictated. If he says "Cholesterol profile" and then just lists the values, then I would put a colon after profile and just list them.
is it okay to transcribe cancer as CA?
Subject: is it okay to transcribe cancer as CA?
account is verbatim and the docs occasionally say it as CA, e.g. CA of the pancreas, prostate CA, etc.
is it correct to transcribe it like that?
how do you transcribe 10 to the fith
Subject: how do you transcribe 10 to the fith
I would just transcribe it verbatim
Subject: I would just transcribe it verbatim
transcribe as dictated...sm
Subject: transcribe as dictated...sm
"neuralgic pain" would be preferred over "neuralgia pain" if you have the ability to edit on the account; otherwise, give them what they dictate =) (best term to use would have been "neuroPATHIC pain" anyway!) =)
I use disc myself for all accounts I transcribe for...nm
Subject: I use disc myself for all accounts I transcribe for...nm
.
it's a legitimate word...if they say it, transcribe it...sm
Subject: it's a legitimate word...if they say it, transcribe it...sm
pus·sy
adj.
Containing or resembling pus.
I agree that pussy is not the most eloquent term used, but if the dictator uses it they obviously don't have a problem with it. If the account is verbatim, type it! If you have QA who get their panties in a wad or think Claudia T. and the AAMT are the LAW, then give them what they want...but it's THEIR issue to overcome...sigh...it's so ridiculous....:)
Help, quick, how do you transcribe 10 to the 3rd per microliter in DQS??? (nm)
Subject: Help, quick, how do you transcribe 10 to the 3rd per microliter in DQS??? (nm)
..
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