Guest guest Posted December 29, 2002 Report Share Posted December 29, 2002 True, but sometimes doctors misspeak. What would you do if you knew something didn't make sense? Sometimes we have to verify what we are hearing if it doesn't make sense or we can't document the word/phrase. This is done in an effort truly do as you say, and transcribe the correct information. We don't guess, or we shouldn't, but sometimes we have to ask someone else, " Hey, this is what I am hearing. Does it make sense to you? Have you heard this before? I can't document it. " Some MTs transcribe for hundreds and hundreds of dictators. Sometimes they don't even get the same one twice. That makes it tough to " get " the difficult dictators. Not only do docs misspeak (and Lord, please don't ever trust their spelling), but they might be Dr. Motormouth, Dr. Yawn-while-dictating, Dr. Sure-I-can-dictate-with-my-mouth-full, Dr. Mumblemush, Dr. English-Is-Not-My-First-Language, or the sound quality might just be bad. Or maybe doc dictates while using the john, or while phones are ringing, or while people are partying in the background, etc. I truly wish it were as easy as just " type what they say, " but it isn't. You will see as you move along in your education. I'll lay money that you will be telling students just what I am telling you after you begin working. We *do* want to transcribe what they are saying, but that's often easier said than done. We have to be knowledgeable enough to know when to question and when not to question. We have to be knowledgeable enough to know when to flag. Medical transcription is both a science and an art. Done correctly, and with quality, it is a very difficult job. Thanks for asking the question. It's a good one and perhaps one that others just beginning their coursework are likely to have. PS. Check out this site for more information: http://pages.sbcglobal.net/kellyratzlaff/kellyratzlaff/dictationguidelines.htm ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Rennie My Home Page: http://www.renesue.com ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Newbie Question. Hi All, I new. Actually getting ready to be a student. Have a question. There seems to be guessing going on? Like with words. When to type exactly what your hearing and when to change it for the Dr's. Am I wrong here? Do they not have basic English education? What if you change it and they didn't want it changed? Your typing something that will become a permanent part of the patients record. I am currently a float secretary and am working in Medical Records at a hospital and have spent months on finding errors in patients records and correcting them. If the Dr. says blue. Why not type blue? Does he himself not know what he means? Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 29, 2002 Report Share Posted December 29, 2002 Just wondering........what kind of patient records are you making changes in. Nothing that the doctor(s) have already signed I hope? Laurilee Newbie Question. > Hi All, > > I new. Actually getting ready to be a student. Have a question. There > seems to be guessing going on? Like with words. > When to type exactly what your hearing and when to change it for the Dr's. > Am I wrong here? Do they not have basic English education? What if you > change it and they didn't want it changed? > Your typing something that will become a permanent part of the patients > record. I am currently a float secretary and am working in Medical Records > at a hospital and have spent months on finding errors in patients records > and correcting them. If the Dr. says blue. Why not type blue? Does he > himself not know what he means? > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 29, 2002 Report Share Posted December 29, 2002 In a message dated 12/29/2002 2:39:52 PM Eastern Standard Time, valpie1@... writes: > You put that SO beautifully and correctly...well....I'm > just....um....speechless!! and of course anyone who " knows " me knows that's > impossible....lol > Here, here! I applaude you Rennie! I am a brand spanking new student and I am so glad you are all out there for help. Dyan Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 29, 2002 Report Share Posted December 29, 2002 Rennie, You put that SO beautifully and correctly...well....I'm just....um....speechless!! and of course anyone who " knows " me knows that's impossible....lol Val Newbie Question. Hi All, I new. Actually getting ready to be a student. Have a question. There seems to be guessing going on? Like with words. When to type exactly what your hearing and when to change it for the Dr's. Am I wrong here? Do they not have basic English education? What if you change it and they didn't want it changed? Your typing something that will become a permanent part of the patients record. I am currently a float secretary and am working in Medical Records at a hospital and have spent months on finding errors in patients records and correcting them. If the Dr. says blue. Why not type blue? Does he himself not know what he means? TO UNSUBSCRIBE send a blank email to NMTC-unsubscribe Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 29, 2002 Report Share Posted December 29, 2002 LOL! Well, gosh, Val, I wuv you too!!! ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Rennie My Home Page: http://www.renesue.com ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Newbie Question. Hi All, I new. Actually getting ready to be a student. Have a question. There seems to be guessing going on? Like with words. When to type exactly what your hearing and when to change it for the Dr's. Am I wrong here? Do they not have basic English education? What if you change it and they didn't want it changed? Your typing something that will become a permanent part of the patients record. I am currently a float secretary and am working in Medical Records at a hospital and have spent months on finding errors in patients records and correcting them. If the Dr. says blue. Why not type blue? Does he himself not know what he means? TO UNSUBSCRIBE send a blank email to NMTC-unsubscribe Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 29, 2002 Report Share Posted December 29, 2002 Just wondering........what kind of patient records are you making changes in. Nothing that the doctor(s) have already signed I hope? Laurilee No, of course not. But, I will tell you that Dr's sign their reports by the hundreds! Not even reading them over after dictated to make sure they are correct. I see things like he instead of she and the other way around. I've seen twins put together in the same chart just because name and birth date are the same. And, I could tell you of other, IMO horror stories with records as hospitals. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 29, 2002 Report Share Posted December 29, 2002 Do you listen to the dictation to see what the doc said? Just curious. RE: Newbie Question. I see things like he instead of she and the other way around. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 29, 2002 Report Share Posted December 29, 2002 Do you listen to the dictation to see what the doc said? Just curious. No, I'm correcting double medical record numbers. I know its a she because her name is Sara. And, under gender it says " F " . I've even found up to three different medical records on the same patient. Did none of you know this was going on? Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 29, 2002 Report Share Posted December 29, 2002 I'm just wondering how a patient having three different medical record numbers is the dictator's fault? That sounds like a patient registration error or medical records clerk error to me. I might have a clue; I've worked in a hospital since 1994. And, if a doctor dictates " blue, " is it " blue " or " blew " ? If there is a question about what they're dictating, you either document it, flag it, or leave a blank. Like Rennie said, I wish it were as easy as " just type what they say. " RE: Newbie Question. Do you listen to the dictation to see what the doc said? Just curious. No, I'm correcting double medical record numbers. I know its a she because her name is Sara. And, under gender it says " F " . I've even found up to three different medical records on the same patient. Did none of you know this was going on? TO UNSUBSCRIBE send a blank email to NMTC-unsubscribe Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 29, 2002 Report Share Posted December 29, 2002 : " Not for nuthin' " but didn't you know you had three major mistakes in your first short letter to us? Outright mistakes, not typos. I'm beginning to wonder if you are serious or just bustin' . . . Excuse me!! Who do you think you are to correct me? I happened to have written the last e-mail while answering the phone and helping my husband with balancing the check book. My work, on the job is perfect!! If it wasn't I don't think the hospital would give me and only me the project of correcting patients charts!! You had NO right to " Check " my work!! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 29, 2002 Report Share Posted December 29, 2002 Here is the process as I see it. Take Rennie's mail and stick it in the back of your mind. Okay. Now you have a report going on and the dictator says something that is not quite intelligible. It could be several different words, for example peroneal, perineal, or peritoneal. You write a question to the list and provide some " limited " background information to augment your question. People on the list, based on prior experience and anatomical/pathological knowledge, put forth some possibilities. You take the possibilities and from what you know and understand, what other information you have in the full report you are transcribing, and what you can document from reliable written/internet sources, you determine what it is you are supposed to be hearing. If you cannot determine this beyond doubt then you certainly do not guess at it. Sadly, having done QA work, all transcriptionists are not as conscientous as most and some do guess. I have no doubt that medical records are full of errors but I believe those of us in this list are here for the very reason that we strive for more. I recall when my wife broke her ankle, and we got copies of all the medical records, there were 3 different accounts of how she broke it documented. It was a trimalleolar fracture but it only happened one time and one way. Dictators/doctors are not free of errors by any stretch of the imagination. I have dictators that will interchange he/she throughout a report and it takes concentration on your part not to get suckered by them when they do it. They will dictate a report about surgery on the left leg and then refer to the right leg about the same surgery. Eny meny miny mo?? They will dictate labs done prior to the patient's date of birth, or currrent hospital events that happened prior to the actual admission date. So this job is not just typing what you hear. Most secretaries could do that. We have to know what we are hearing and understand it before we put it in the document. Quixote wrote: > Hi All, > > I new. Actually getting ready to be a student. Have a question. > There seems to be guessing going on? Like with words. > When to type exactly what your hearing and when to change it for the > Dr's. Am I wrong here? Do they not have basic English education? > What if you change it and they didn't want it changed? > Your typing something that will become a permanent part of the > patients record. I am currently a float secretary and am working in > Medical Records at a hospital and have spent months on finding errors > in patients records and correcting them. If the Dr. says blue. Why > not type blue? Does he himself not know what he means? > > > > > TO UNSUBSCRIBE send a blank email to NMTC-unsubscribe > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 29, 2002 Report Share Posted December 29, 2002 >Here is the process as I see it. <snip> Quixote, That is a beautiful explanation! If you don't mind, I will borrow this when explaining to my friends why I am enrolled in the M-TEC program to become an MT. I've had lots of " Oh, anyone can type dictation! " responses to my desire for a career as an MT. -Allie Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 29, 2002 Report Share Posted December 29, 2002 : " Not for nuthin' " but didn't you know you had three major mistakes in your first short letter to us? Outright mistakes, not typos. I'm beginning to wonder if you are serious or just bustin' . . . RE: Newbie Question. Do you listen to the dictation to see what the doc said? Just curious. No, I'm correcting double medical record numbers. I know its a she because her name is Sara. And, under gender it says " F " . I've even found up to three different medical records on the same patient. Did none of you know this was going on? TO UNSUBSCRIBE send a blank email to NMTC-unsubscribe Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 29, 2002 Report Share Posted December 29, 2002 , Are you putting us on, or what? I believe you probably should take a trial run at " walking in our shoes " before you judge us. I hope you don't think you can multitask like this when you are an actual MT. " NO right to " Check " my work " -- I hope this is not an attitude you take to your job or that you intend to carry into your academic future or your MT career. Perhaps, at your job, if the errors you find are on reasonably fresh dictation, you could request to listen to the dictation, then you might have a clue as to what the problem was/is. Also, you must remember that, I would say, most of us do not have access to the full chart to double-check things like drugs, dates, etc. We can only use our " common sense " to either figure things out or flag the item for clarification. We are all professionals here and I believe we all ask questions to further our knowledge. MT is a career where one must continually strive to improve oneself and keep abreast of ALL changes in the medical field, grammatical field, etc. In many ways, I feel -- at least, more knowledgeable than many other medical professionals as we have to keep abreast of changes, new things, etc. in all medical specialties -- not just a little niche, etc. Thanks for listening, all -- Gai RE: Newbie Question. > : " Not for nuthin' " but didn't you know you had three major mistakes > in your first short letter to us? Outright mistakes, not typos. I'm > beginning to wonder if you are serious or just bustin' . . . > > Excuse me!! Who do you think you are to correct me? I happened to have > written the last e-mail while answering the phone and helping my husband > with balancing the check book. My work, on the job is perfect!! If it > wasn't I don't think the hospital would give me and only me the project of > correcting patients charts!! You had NO right to " Check " my work!! > > > > > > TO UNSUBSCRIBE send a blank email to NMTC-unsubscribe > > > Quote Link to comment Share on other sites More sharing options...
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