A community of 30,000 US Transcriptionist serving Medical Transcription Industry

What I've seen since leaving MT - memt

Posted: May 01, 2012

I recently left the MT field but am in a position where I have to review medical records daily. I've come across mistakes that make me question where they came from... was it a VR report that an editor didn't catch... was it a transcription error... or was it a doctor error. Some of the things I've come across were a statement along the lines of "would've healing well"... I figure this was supposed to be something like "wound is" healing well. I came across a discrepancy between right finger and left finger injury. Another one was where someone was hit in the head and a "trunk" was taken out of his scalp... did you mean "chunk"? The last one I can think of is where the date of injury on the medical record was a month off. It really is interesting to see the mistakes that are present in the final medical record but now seeing it from a different position. I would imagine I view these medical records with a different perspecive than the others in my same position. I realize what has gone into producing that record, whereas the others just see the final product and have no idea that it may have been produced by a computer or maybe even an Indian or Pakastanian typed it who doesn't even understand the English language. I am spreading the word about offshoring when given the opportunity. I don't think anyone I've mentioned it to was aware of it.

I've NEVER seen someone aware of it - AnonToo

[ In Reply To ..]
Where I work it's not uncommon for a doctor to dictate the social security number AND ADDRESS of someone on a preadmit H&P. We *do* offshore and this stuff is out there. Let alone the date of birth which is always dictated. I don't think the doctors even realize how crappy some of this stuff is transcribed, but on the other hand if they want to pay minimum wage or less for something they sign and is something they need to back them in court..I guess that's the dealio.

At the hospital I work for, the doctor - need-a-vacation

[ In Reply To ..]
can go in and change reports. I recall going back to check on one and saw an added sentence with capital letters where they didn't belong, a period was missing, and a body part was spelled incorrectly. My name was on the report but the audit trail showed the doctor had changed the report. Anyone viewing this report would probably blame the MT.

Another thing I've noticed with the same account is they must be using VR in admitting or the ER because some of the fields we don't fill in, like admitting diagnosis, have strange errors, for instance, internal jungle vein trombones is. That error shows up on every report generated on that patient.

Voice recognition software at fault - GrammyMT

[ In Reply To ..]
Most of those type errors that I have seen are caused by voice recognition software.

These same doctors are so picky when there is an MT to blame, but when it is a software package, it is "acceptable?" I sure don't understand it.

records - me

[ In Reply To ..]
I love that you don't want to pound home that sometimes US MTs are inept. They are sometimes. Many who THINK they are wonderful, are not. You say you have no clue how this record was produced. I find it wrong that you assume you now need to educate about offshoring because a record was not accurate. I see mistakes like this all the time -- done by US MTs.

I have to agree - AnonToo

[ In Reply To ..]
I worked part time for a small service, now she's got 100 employees. I did QA. Most of our transcriptionists lived on the Gulf in Mississippi and I would say MOST OF THEM would type "The patient was walking at the GOLF" all the time. They could not seem to get their/they're/there in their heads. I have seen "tale of the pancreas" and when corrected over and over (different people) it was still tale. I finally sent a massive memo to ALL of them that there is no TALE of the pancreas unless there is a STORY of the spleen (with the owner's blessing). Some of these were CMTs. I think also most of them were doing this job (we had no set hours) in between child care and attention was not on the job. I was the ONLY one that had any in house experience. I left because of the fact that it seemed like the only thing that mattered was getting the reports out, not being remotely accurate..but the company continues to grow and she most definitely does NOT offshore or can afford SR.

Sadly, yes. I'm sure I'm not the only one wincing at - the incompetence displayed here in many posts. NM

[ In Reply To ..]

sadly, I also have to agree - sm

[ In Reply To ..]
we are fond of thinking that those offshore don't speak good English, but the stuff I see coming from US MTs is just plain sad.

This is the reason I quit QA and went back to transcribing - Ayn

[ In Reply To ..]
Got so tired of banging my head against the wall with MTs who had years of experience (10-20+ years for some) and thought that made them immune to making errors. I'm talking simple English grammar, punctuation, and spelling that we all learned in 3rd grade. Heaven forbid I tried to correct them though!

And you can forget about them being willing to learn a new medical word or procedure. If I heard "that's now how I learned it 15 years ago" or "that's not how we did it before" one more time I think I would have killed someone. Folks -- things change & new things are discovered every day!!

OK, rant over :-) Glad I'm not the only one who gets discouraged by some of the crap I see from American MTs.

My recent experience - countryMT

[ In Reply To ..]
I transcribed a report. Blanks in report because of skips in dictation. Doctor just took out blanks and left incomplete sentences throughout. When someone looks at the report, who are they going to blame? Me. The person whose initials are at the bottom. Certainly not the doc.

Ouch! You need to get yourself on the record in writing - about this happening. Mercifully,

[ In Reply To ..]
my company has finally changed the system to record each person in a record and changes made. It's been a long time coming. Some time ago I was blamed for a critical plus sloppy errors entered in a report (a style of errors I never make, so obvious to me), by whom I don't know, but like you mine was the name on the system.

Front end voice recognition - aventurinegreen

[ In Reply To ..]
While dressing in a locker room at my local health club, I overheard a conversation. This woman (job?) was disgusted because no one proofs what the doctors dictate via voice recognition. It goes into the record exactly as recorded. I caught up to this woman and asked if they didn't have editors. She said no they didn't. She did not want to give me the name of hospital or clinic. Maybe that's where your reports are coming from.

What I have seen also - just me

[ In Reply To ..]
I will have to agree. What I see during editing is sad. Patients are listed as male but female in the body of report, incorrect spellings, medication errors (enough to kill the patients, right versus left incorrect, and do not even get me started on grammar and punctuation. I have 96 physicians as clients, and yes they do care about grammar and punctuation and do recognize when you correct their spelling and verbs as well and appreciate it very much.

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