Patient Heading Information.

[Guest guest]

How many of you actually put the patient's information on the actual

report that you transcribe for your employer?

Example would be:

Patient's Name:

Hospital No.:

and so on.

In my first transcription class this information was given, but in my

last transcription class this information is not even used in the

class due to confidentiality.

Thanks.

Patty Jo

[Guest guest]

I work for a national, and most of the time, the patient information is

already there. If it isn't I can add what the doctor gives, but it gets a

defy code to be routed to completions to put the info in.

Jan

jantranscribes@...

" Typing is my life. "

" Whoever signs the paycheck makes the rules. "

Patient Heading Information.

> How many of you actually put the patient's information on the actual

> report that you transcribe for your employer?

>

> Example would be:

>

> Patient's Name:

>

> Hospital No.:

>

> and so on.

>

> In my first transcription class this information was given, but in my

> last transcription class this information is not even used in the

> class due to confidentiality.

>

> Thanks.

>

> Patty Jo

>

>

>

[Guest guest]

For my local doc, I type in the patient's name, chart number, and date. For the

National, with the account I have with them now, they forbid use of patient

name. If the doctor dictates it, we are to type " the patient " or " she " or " he " ,

whatever. Spouse's name, same way. Looks like a pretty good way to me to keep

confidentiality intact! We type in the Patient Record number and the Job Number

for each one in the header section,

Carol in NC

MedQuist - Hospital notes, all specialities

Internal Medicine

Patient Heading Information.

> How many of you actually put the patient's information on the actual

> report that you transcribe for your employer?

>

> Example would be:

>

> Patient's Name:

>

> Hospital No.:

>

> and so on.

>

> In my first transcription class this information was given, but in my

> last transcription class this information is not even used in the

> class due to confidentiality.

>

> Thanks.

>

> Patty Jo

>

>

>

[Guest guest]

I wasn't required to when I started this account, but have started naming my

files with the date of visit, patient initials, and dictator's intitials,

like so: 7-17-03--LVC-dx, and putting that at the beginning of each report

as well as the " continued " line. The previous method was just to write in

the pt. name and DOB after printing out the report, and only including the

date of visit in the " continued " line for subsequent pages. You will find

that much of what you learn in school about formatting will have very little

to do with how the account you eventually get wants things done. :-)

Lynn

Patient Heading Information.

How many of you actually put the patient's information on the actual

report that you transcribe for your employer?

Example would be:

Patient's Name:

Hospital No.:

and so on.

In my first transcription class this information was given, but in my

last transcription class this information is not even used in the

class due to confidentiality.

Thanks.

Patty Jo

TO UNSUBSCRIBE send a blank email to NMTC-unsubscribe

[Guest guest]

So then someone else in the office would have to fill the information on the

report to complete it with the pt name, etc., or does it go in the pt's file

with only the pt record number and job number.......

try'n to visualize how this works.....c

-- Re: Patient Heading Information.

For my local doc, I type in the patient's name, chart number, and date. For

the National, with the account I have with them now, they forbid use of

patient name. If the doctor dictates it, we are to type " the patient " or

she " or " he " , whatever. Spouse's name, same way. Looks like a pretty good

way to me to keep confidentiality intact! We type in the Patient Record

number and the Job Number for each one in the header section,

Carol in NC

MedQuist - Hospital notes, all specialities

Internal Medicine

Patient Heading Information.

> How many of you actually put the patient's information on the actual

> report that you transcribe for your employer?

>

> Example would be:

>

> Patient's Name:

>

> Hospital No.:

>

> and so on.

>

> In my first transcription class this information was given, but in my

> last transcription class this information is not even used in the

> class due to confidentiality.

>

> Thanks.

>

> Patty Jo

>

>

>

[Guest guest]

For the clinic I used to work for, I picked up paper progress notes

that already had the header info on labels on the notes themselves.

It was only recently that we were required to type the patient's

name, MR number and date of service on the very first line. This was

because we saved the progress notes in " runs, " i.e., all of Dr.

on July 17 in 1 document basically, with each patient on a different

page in the document. It was also so that Quality Assurance knew that

we had the right dictation and date on the right page. When I did op

notes, then I had to type as you have noted. For the company I now

work for, we do not use the name at all, just " the patient, " etc. The

only time I type a name would be if the patient number entered into

the separate header program would come up incorrect, and then if the

doc gives a name (which they don't all do), I would type it on the

first line. You will find that every place varies in how they want

things done, sometimes even from doc to doc within the same

clinic/hospital/group. Good luck!

Carolyn

> How many of you actually put the patient's information on the

actual

> report that you transcribe for your employer?

>

> Example would be:

>

> Patient's Name:

>

> Hospital No.:

>

> and so on.

>

> In my first transcription class this information was given, but in

my

> last transcription class this information is not even used in the

> class due to confidentiality.

>

> Thanks.

>

> Patty Jo

[Guest guest]

Patty Jo, In all of my transcriptions as a student, no names are ever used.

Not even the doctor's names are mentioned. Dyan

[Guest guest]

Yes, but that's because you're a student, the same as any sample reports or

reports used for testing purposes would have to have all identifying

information removed. The employer or client has to decide whether the

patient name should be transcribed, or " the patient. " It is totally up to

the client or the employer to decide, not the MT, per the online HIPAA class

I took.

Jan

jantranscribes@...

" Typing is my life. "

" Whoever signs the paycheck makes the rules. "

Re: Patient Heading Information.

> Patty Jo, In all of my transcriptions as a student, no names are ever

used.

> Not even the doctor's names are mentioned. Dyan

>

>

>