Verbatim and heading

the doctor is dead wrong about his anatomy? The patient has a problem with his foot and leg, but he dictates ulna. I wouldn't give it a second thought to leaving it blank, but I already got notice about documents with blanks (usually 1-2 blanks if any, and anymore than 3, to QA). Hmm... go with what is right or what is the least path of resistance (i.e. least likely punishment) BTW - The document I sent yesterday with 4 blanks to QA, they couldn't fill them in either. Shesh, the ...

The reason I ask is because this morning I'm doing an acute care progress note where the dictator says "The patient has end-stage chronic obstructive pulmonary disease and she is still sounding pretty crappy and congested." I absolutely refuse to use the word "crappy" in a medical document if it is not within the context of a direct quote from the patient, i.e. "I feel pretty crappy..." So I decided to omit crappy and just say "she is still sounding pretty congested." QA w ...

This doctor describes the preop/postop diagnoses, type of anesthesia, and gives the surgeon's name (all of which I made separate headings for as it seemed he was dictating them). After the surgeon's name, he goes into a short description of the patient and a few physical exam findings as they pertain to the procedure. He does not dictate a heading or anything, although after his description of the patient, he dictates a new paragraph and a PROCEDURE heading. Should I put a ...

Dr. says Problem hashtag.....brain fart....do I number the problems? thanks. ...

talking about infected cysts under her arm in the axilla. would this go under trunk or extremities? Thank you ...

Dictated problem list: Transcribed problem ...

See y'all in 6 minutes.... :) ...

I have a couple of doctors who dictate without giving headings--I'm supposed to add these. What heading would I put "perineal exam" under in this report? He dictates it after the abdominal exam, but would that be the appropriate section to put this under? I thought of pelvic, but it really isn't a pelvic (female patient). ...

A friend suggested transcribing for the deaf, requires passing a 180-200 wpm test from conversation. Anyone done/doing this? It is a great consolation to get all of your support. MT Stars is wonderful to give us this opportunity. MQ never was able to maintain a professional forum. ...

We have just updated to Docqscribe 6.1 at our facility. Does anyone know if you can use the heading list function just for straight typing as we do not ASR. ...

I hear the doctor say Nature and Duration...Patient was admitted to ___ [PLACE]..... Is that right??? need serious help!! ...

I thought that DQS 6 was bad, but this 7.1 certainly topped that one. It seems to just randomly makes words headings whenever it feels like it. Just now, on a dictation clear as day, in the middle of a sentence, it decided that the word "the" was to be a heading. Why? ...

If you find missing text at the end of a sentence and a heading following, restore the heading ctl+shift+H and it usually is hidden under there..dont know why but you know they arent gonna fix it, so may as well try especially on those hard to figure out words. ...

In transcribing a letter should Doctor's be capitalized: Dear Doctor's or doctors? ...

Thereafter he was seen at the student health center where evaluation was undertaken. ...

Gait testing is part of the neurological examination and should therefore go under that heading. From my perspective, healthcare document integrity should hold sway over account specs or doctor preferences. Too many doctors think all that matters is what they say or how they interpret what is said, which is total bunk. If that were true, we would all just start typing melanotic stools every time one of these medical geniuses dictates that because certainly there isn't a do ...

This is EXACTLY how it was dictated: I cleansed the skin with alcohol from her prior visit (LONG PAUSE) I do remember patient having a very low pain tolerance. That's pretty unsanitary to use alcohol from the prior visit, don't ya think? LOL ...

This is almost/sort of a poll. I need to know what verbatim means to you in VR. Do you change any wording? My understanding of verbatim is word-for-word (Merriam-Webster dictionary) unless a sentence does not have proper structure; if the doctor rambles on and puts the word 'and' between words where there should be a period, etc. (Not included in this is changing mg to mcg in a wrong dosage, changing the medication itself if wrong, or other major medical erros&nbs ...

Just worked on an ESL report (with unfortunately for me very, very, very little English). This is a VERBATIM account. Sent it to QA and it was "transformed" into English with little regard for that pesky word VERBATIM. Does verbatim mean different things to different people? ...

If not specified, is it better when taking an employment test to type verbatim or to follow transcription rules? Not asking for a specific test or company, I have just noticed that often times no instructions are given, and I don't know whether they are looking for following transcription/AHDI rules or just running the test next to a template in the system. ...

lisinopril/HCTZ 20/125. I'm sure she meant 12.5 but she clearly says 125. I don't want to leave a blank as I get penalized. I'm thinking to just do as I know and put 12.5.... ...

Hi everyone I may be getting a job which is a verbatim account. I have not done that much verbatim work and I was wondering, are there any tips I need to know about doing such an account ? I realize that verbatim means exactly the same words but if any of you have any tips typing verbatim I would really appreciate it. Thank you in advance and I hope everyone has a great week. ...

significant for hypOtension and a few diagnoses down from that hypeRtension. I would leave it a blank if it did not cost me money but not sure she meant the hypOtension. She repeats herself alot but she clearly says hypOtension. It's a guessing game! ...

Is it me or what - I was always told to follow account spec and make sure I didn't use the forbidden JCAHO abbreviations. Lately if I look at an old report to get a slurred/muffled word that I can't make heads or tails out of, I've noticed that others on my same account don't follow the specs at all! They do everything verbatim. It totally upsets me. I noticed it a while back and put it down to a new employee not yet knowing all the specs, but it wasn't as ba ...

would you just put pip-tazobactam?? I'm also thinking she made a mistake saying pip which I know is piperacillin. Thanks so much! ...

How are you liking it so far? ...

I have all verbatim-verbatim accounts and only just now learned that we have to change what the dictator says and change it to an "approved heading." I was once told this only pertained to non-verbatim accounts, but was just corrected. I was told that ALL OF THE CHECKED headings in the headings pane must be included in the document. If the doctor says procedure, you must put in an approved heading into the standard changing what he says if in the approved headings list it says ...

Verbatim and heading - henderlor

the facility makes that call, not AHDI - BOS is recommendation not law

Indeed - MT

What is AHDI going to do to you if you - choose

Unfortunately, it's MTSOs and QA drinking the Kool-Aid (nm) - anon

Stand up against the AHDI - Berkeley gal

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