It may depend on the account, but I think most
Posted By: me on 2007-05-08
In Reply to: You don't add in mg or mcg, etc. unless it's dictated. The docs know - what they mean when dictated. nm
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.
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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.
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.
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
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
.
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.
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.
I think it would depend on the drug....
Subject: I think it would depend on the drug....
??
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
Depend if the doctor says it and it is a verbatim acct.
Subject: Depend if the doctor says it and it is a verbatim acct.
x
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
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
x
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
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.
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...
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.
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
I hear it a lot on this account.
Subject: I hear it a lot on this account.
but I have looked on previous reports and seen where MTs type Mabex but I cannot reference it so I blank it and send it on. Just wondered if anyone else heard of it.
And did you say what kind of account
Subject: And did you say what kind of account
or what the specialty is? If you hear it a lot, it is probably related to the specialty you're doing.
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.
I would change it since account not
Subject: I would change it since account not
verbatim. LOL "hook up with"
Doctors are so funny.
New urology account
Subject: New urology account
 I'm being asked to help on a new account for me - urology. I have done a pelvic pain doctor who treats females so I might be familiar with some things there. Any good sites that you could recommend for research in case I get stuck?
if your account allows symbols use #
Subject: if your account allows symbols use #
nm
Depends on your account. nm
Subject: Depends on your account. nm
nm
On my account we cannot use slang so
Subject: On my account we cannot use slang so
x
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.
Do not know the leeway given for your particular account, but I would...
Subject: Do not know the leeway given for your particular account, but I would...
The patient was able to answer questions such as "what color is the sky?" and "how many eyes do you have?"
The patient responded "yes" to the statements "I feel lonely" and "sometimes I feel depressed."
Thank you so much! A new account/dictator. nm
Subject: Thank you so much! A new account/dictator. nm
nm
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