Type it exactly as the doctor dictates, verbatim....nm
Posted By: - on 2009-05-02
In Reply to: Fixing dictations. - sm
Subject: Type it exactly as the doctor dictates, verbatim....nm
nm
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The doctor dictates
Subject: The doctor dictates
His aortic valve appeared well-(s/l seated). I found some examples like that, but am unsure of certainty and spelling accuracy? Thank you in advance for any help.
Doctor dictates ALT 1413 and AST 681? Should it be 14.31 and 6.81? TIA!
Subject: Doctor dictates ALT 1413 and AST 681? Should it be 14.31 and 6.81? TIA!
Doctor dictates Actos plus met 15/850 mg daily. nm
nm
doctor dictates and spells cellulagia
Subject: doctor dictates and spells cellulagia
I cannot find or verify this anywhere. Is this even a word?
Formatting when doctor dictates "question..."
Subject: Formatting when doctor dictates "question..."
Dictated: "Patient was prescribed question Pyridium"
How would I transcribe this? Would I type, "Patient was prescribed Pyridium?"
Thanks in advance!!!!!!
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".
Thank you. This particular doctor isn't verbatim so I'll use that! :)
Subject: Thank you. This particular doctor isn't verbatim so I'll use that! :)
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
he is dictating is backwards. I would type it as he dictates...nm
Subject: he is dictating is backwards. I would type it as he dictates...nm
xx
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
My MD dictates all the time, "perimenopausal symptoms" I can't document. Should I type it
Subject: My MD dictates all the time, "perimenopausal symptoms" I can't document. Should I type it anyway?
I would type it verbatim.
Subject: I would type it verbatim.
When doctor says tib-fib, do you type it like that or do you type tibiofibular? Thanks
.
If all else fails, I usually type verbatim just as you have it
Subject: If all else fails, I usually type verbatim just as you have it
If verbatim I would type desats, if you are
Subject: If verbatim I would type desats, if you are
not supposed to use slang then spell it out.
I would type verbatim within the guidelines
Subject: I would type verbatim within the guidelines
of the BOS. In other words, I would not type contractions, slang, or prohibited abbreviations. If the account wants you to ignore the BOS once you get the job, that's fine, but I think it would be better to show your knowledge of the BOS and get it wrong than to disregard the BOS altogether.
if it is strictly verbatim, I type gotten..nm
Subject: if it is strictly verbatim, I type gotten..nm
nm
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.
If not verbatim, may also type 2-year-8-month-old...nm
Subject: If not verbatim, may also type 2-year-8-month-old...nm
x
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
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
You would be guessing here, so I would type verbatim and flag
Subject: You would be guessing here, so I would type verbatim and flag
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.
Good semantics question, but in my opinion I would type it verbatim.
Subject: Good semantics question, but in my opinion I would type it verbatim.
I used to type for an orthopedic doctor who (sm)
Subject: I used to type for an orthopedic doctor who (sm)
used this word quite frequently. I could never ever document it, but upon asking him directly he told me to spell it as "sorseal" Again, I could never document it, and he was the only doc who used that particular term. If you do find out what it is supposed to be, I would LOVE to know!! :)
whether or not the doctor is a whom type of person,
Subject: whether or not the doctor is a whom type of person,
whom is correct either way you type it. Who is not. Just a little grammar pet peeve of mine. Even with the preposition at the end of the sentence, it should be whom.
I would type "BICAPed" since the doctor is misusing the term.
Subject: I would type "BICAPed" since the doctor is misusing the term.
verbatim is VERBATIM....bad advice he gave you.....
Subject: verbatim is VERBATIM....bad advice he gave you.....
if the doctor says 'Aczone top', then type 'Aczone top', no periods...nm
Subject: if the doctor says 'Aczone top', then type 'Aczone top', no periods...nm
nm
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
Under PMH. MD dictates: sm
Subject: Under PMH. MD dictates: sm
Status post trauma/repair to patient’s eye.
Would you leave this as is with the slash or change it? I am permitted to change things when necessary. Thanks.
What do you do when the doc dictates sm
Subject: What do you do when the doc dictates sm
... and I gave the patient 50 "mikes" of whatever medication. One said to spell it m-i-q-u-e-s, one said to use m-i-k-e-s, and one hospital said not to use it at all. So, does it stand for micrograms? Should we use slang? Aghh! Help, please.
I would put as doc dictates..sm
Subject: I would put as doc dictates..sm
if he says "calcium one every day" I would not input the q.d., but I would expand it as "calcium, one tablet every day." jmo and how I have been doing it with no complaints.
Exactly the way MD dictates it
Subject: Exactly the way MD dictates it
If the patient could see anything at all (I had one today where the patient could see 20/1760), then the MD would have given the value, but when there is nothing there, you just type nothing. I have a verbatim account, but even if I didn't, I still would not change it to 20/0 as that lone "0" could be mistaken as something else.
If a Dr. dictates
Subject: If a Dr. dictates
"posterior tib", meaning posterior tibial artery, do you type the abbreviation or go ahead and type out tibial?
if that's the way he/she dictates it...then yes I would. nm
Subject: if that's the way he/she dictates it...then yes I would. nm
xxx
Think that one is bad? my md dictates things like this...sm
Subject: Think that one is bad? my md dictates things like this...sm
I used a small, tiny, little Q-tip .... and he doesn't want me to change it. Bizarre!!!
I have a doc that dictates same thing
Subject: I have a doc that dictates same thing
mine means adenosine thallium
I leave it as whatever the doc dictates.
Subject: I leave it as whatever the doc dictates.
It's not my job to keep them politically correct.
Do I change it when he dictates cc? nm
Subject: Do I change it when he dictates cc? nm
!
I have a psychiatrist who dictates like that. sm
Subject: I have a psychiatrist who dictates like that. sm
I leave most of his stuff as is even though the account is not verbatim. A lot of times I end up wondering WTH he is talking about. When I first got his dictations I was going back to read and relisten because I thought I must have scrambled something. Give them what they dictate, if they don't like what they read maybe they'll take the time to think before they dictate next time.
when doc dictates L-thyroid sm
Subject: when doc dictates L-thyroid sm
Does he mean levothyroxine or Levothroid?
Dictates died s/l **min** CVA
Subject: Dictates died s/l **min** CVA
Dictates died from m-i-n CVA. I can't verify min CVA anywhere. Any suggestions?
dictates **phagiagram**
Subject: dictates **phagiagram**
He clearly dictates *phagiagram* or something that is VERY similar to that. I don't hear a *dys*. I tried google and am getting zero hits.
Do you think I should I QA it or would it be fine to just use *phagiagram*?
Thanks in advance.
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.
I have an ESL who dictates a lipid profile
Subject: I have an ESL who dictates a lipid profile
and then says "lipid profile comment NIHN." What in the world does that mean?
whatever doc dictates. Would not use beats/minute tho. nm
Subject: whatever doc dictates. Would not use beats/minute tho. nm
Yes. I transcribe for a cardiologist who always dictates
Subject: Yes. I transcribe for a cardiologist who always dictates
Could be, although he only dictates 1 syllable. I think I will flag. Thanks.
Subject: Could be, although he only dictates 1 syllable. I think I will flag. Thanks.
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