Hospital v. At-home

[Guest guest]

This is just something that I thought of regarding the current discussion of

mistakes found in hospital charts, etc.

I know that several folks on this list work at home, some for hospitals,

some independently, some for national companies, etc. There is different

quality review for all of us. Also, some accounts require the MT to

transcribe verbatim and then those reports go through QR before going to the

client. I work in the hospital, and I am my own QR. Of course, I have

access to the charts if need be to document information, and we have a

system in place to make the doctors aware of any blanks or incompletes we

have. I am able to edit as necessary, and I do so with a light hand.

I think most of us realize that these doctors are extremely busy and see

probably 40+ patients per day, not to mention phone calls, rounds at the

hospital, dictating, etc. I respect their knowledge and the fact that they

are very busy. I may grumble about them on the list, but I try to support

them the best way I possibly can in this area of their healthcare provision

to their patients. I also feel that it helps us to gain *their* respect if

they are aware that they have *our* respect. Of course, that doesn't apply

to all doctors, by no means! Or all MTs, for that matter. In my case, if I

blanked every little piddly error a dictator made, I imagine no one would

ever get paid! If they give me a wrong medical record number, thankfully I

can look it up and correct it. If they give me a wrong dosage, thankfully I

can pull the chart and document it. There are occasions, though, where it

requires the dictator's attention, and my doctors appreciate the fact that

we catch an inconsistency and made them aware without barking at them to

dictate with grammatically correct English and spelling and know all the

dosages for all the sound-alike drugs.

And when I sent a suggestion through earlier regarding peak flow and I told

the person that " it was just a guess " I meant exactly that and that person

should obviously not just put my suggestion in her report willy-nilly

without first documenting it. That was my " guess " to her sounds-like

question and that was my way to let her know it was just a guess instead of

telling her " You are hearing 250-300. " I had not even *heard* the

dictation!! Sorry if that caused any confusion.