Open letter to medical records directors: Get your act together - and establish a SINGLE doc standard. Posted: Aug 20th, 2016 - 9:54 am
In the year 2016, it's beyond ridiculous that each and every one of you is still clinging to your own set of petty "preferences" with regard to the healthcare document. These preferences, I might add, are in many cases entirely irrelevant to either the quality or the medical utility of the patient's record, and are more often simply trivial and niggling, rather than useful or substantive.
I work on three different accounts, each with from 10 to 20 pages of single-spaced "client preferences." Let me give you a few examples:
Report title:
* Client #1 insists that the title be rendered as whatever the dictator says. If he says "Admission H and P", or "Preop Admission Note", that's how the title is to be transcribed.
* Client #2 wants the title rendered ONLY as one of the "approved" work types, in this case "History and Physical", regardless of what the dictator says.
* Client #3 is silent on this matter, providing no guidance whatsoever.
Blanks:
* Client #1 wants reports to be pended for MTSO review if there are 3 blanks.
* Client #2 wants reports to be pended if there are 4 blanks.
* Client #3 wants reports to be pended if there are 3 blanks.
Ordinals:
* Client #1 wants "first", "second", etc to be rendered as such.
* Client #2 wants them rendered as "1st", "2nd", etc.
* Client #3 is silent.
Disease Stages and Grades:
* Client #1 wants stages to always be rendered in Roman numerals, even if that is NOT the practice of the specialty in question.
* Client #2 wants stages to be rendered as the specialty expects, grades always in Arabic.
* Client #3 wants stages to be rendered in Arabic, grades as per specialty expectations.
So, here's what happens in case you didn't know. Any time someone comes onto YOUR account, they must be trained in YOUR little stupid peccadilloes.
This almost always means an hour or two of MTSO "training time", for which the MT must be paid at least minimum wage.
Then, it almost always means a period in which the MT's work must be on "full review" - meaning it is put on hold and delayed getting to you while someone ON SALARY reviews every report they transcribe.
JUST SO YOU DON'T BECOME ENRAGED AND THREATEN TO YANK YOUR ACCOUNT.
What in the hell are you people playing at?
I'm really going to go out on a limb here. The truth is, I SUSPECT THAT MUCH OF THIS IS RELATED TO THE FACT THAT WOMEN DOMINATE MEDICAL RECORDS AND WOMEN DEMONSTRABLY CANNOT AND WILL NOT WORK TOGETHER.
Men would have solved this problem a LONG time ago. Sorry, but I have extensive experience in two different fields where MEN dominate the decision-making population and I know what I'm talking about.
Women need to consider their inherent weaknesses when it comes to cooperative action - which men solved back in the cave. And you need to consider yours.
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