You should dictate what the doc says.
Posted By: sm on 2006-02-27
In Reply to: Barrett's - lola
Subject: You should dictate what the doc says.
If he is wrong, that's his problem. You can't just go changing what he says unless you have free reign on your account.
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- Barrett's - lola
- You should dictate what the doc says. - sm
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Drs get what they dictate - some of us only do..S/M
Subject: Drs get what they dictate - some of us only do..S/M
brachioplexus, brachioplexopathy - what they say is what they get....client profile RULES!
How does he dictate it? Is he actually - sm
Subject: How does he dictate it? Is he actually - sm
Is he saying "CBC, MSP, and stool" because stool is not a test so just wondering if it could be the name of a stool test. If you state just how the whole sentence is dictated, it may help us figure it out for ya.
I had a doc used to dictate that
Subject: I had a doc used to dictate that
Good says it stands for keep-open-vein. So, it should fit, and it also is all CAPs. 
Usually if they dictate Seldinger...
Subject: Usually if they dictate Seldinger...
they will say "via Seldinger, or Seldinger technique." I don't believe they would do this en route either. Are you sure you are hearing "sandwich?" I have been transcribing ER reports for years and I have never heard this term used. Anyway, I would not guess on this one. IMO, it is better to leave it blank and have QA inform you later so you can keep it on file  .
Yes, that was how I was taught and most always they dictate cc nm
Subject: Yes, that was how I was taught and most always they dictate cc nm
nm
welcome; got it from my docs that dictate it as i never could figure them all out either, lol. nm
;
Sorry, but I have had them dictate brain or beta.
Subject: Sorry, but I have had them dictate brain or beta.
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).
Did she dictate the colon after "murmur?" nm
Subject: Did she dictate the colon after "murmur?" nm
x
no matter what they dictate, they are wrong...nm
Subject: no matter what they dictate, they are wrong...nm
LOL..the way these docs dictate anymore
Subject: LOL..the way these docs dictate anymore
who knows!! Something like that just check your aspirin bottle. Good luck!!
doctor didn't dictate mg????
Subject: doctor didn't dictate mg????
The patient was given aminophylline, Lanoxin 0.25, Lasix 40 mg, Cardizem.
okay here the doctor fails to dictate mg? according to 'textbook rules' do I add this or not?
Lordy, when they dictate commas it is just sm
Subject: Lordy, when they dictate commas it is just sm
like a poke in the eye to me!!! Brings me to a screeching halt. I just tend to ignore them, in a report, especially if it is a resident. I do puncturate letters and memos, but half the commas I see people use on this board and other boards are totally not necessary. Just call me
anti-comma!!!!!
If you dictate the full sentence I could probably help you figure it out. nm
Subject: If you dictate the full sentence I could probably help you figure it out. nm
Thanks for finding that. I just had doc today dictate this...hmmmm
Subject: Thanks for finding that. I just had doc today dictate this...hmmmm
doc didn't dictate that....her brain was thinking that...
Subject: doc didn't dictate that....her brain was thinking that...
nm
Thought so thanks wish they would dictate the drugs correctly
Subject: Thought so thanks wish they would dictate the drugs correctly
or may be mistakenly thinking of their pet's food as they dictate?
Subject: or may be mistakenly thinking of their pet's food as they dictate?
wrong - they ALL dictate decubiti...no such word
Subject: wrong - they ALL dictate decubiti...no such word
did he dictate the point, or did he say 1 5, to make sure you did not hear 50
Subject: did he dictate the point, or did he say 1 5, to make sure you did not hear 50
nm
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.
Derm docs often dictate "Allergy to CARBO mix" - sm
Subject: Derm docs often dictate "Allergy to CARBO mix" - sm
I don't know what the full word is, but this validates your hearing the partial "carbo"
Long shot, but often dictate myocardial ischemia. nm
Subject: Long shot, but often dictate myocardial ischemia. nm
xx
Macrobid (nitrofurantoin) is commonly used, maybe doc stumbling on whether to dictate brand name or
Subject: Macrobid (nitrofurantoin) is commonly used, maybe doc stumbling on whether to dictate brand name or generic?
there is the abbreviation MAR docs dictate for medication administration record, but not sure...sm
Subject: there is the abbreviation MAR docs dictate for medication administration record, but not sure...sm
if that's it? This is usually dictated when they don't want to list the entire medication list so refer to the MAR that is in the chart.
Pupils equally reactive to light, they do not always dictate the whole exam abbreviation, they ..sm
Subject: Pupils equally reactive to light, they do not always dictate the whole exam abbreviation, they ..sm
do not always examine all aspects on PE. Hope this helps!
Don't be confused by dift opinions. Blank if unsure. However, docs dictate one-teens all the ti
Subject: Don't be confused by dift opinions. Blank if unsure. However, docs dictate one-teens all the time.
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