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

Appalled at what a medical record looks like now. - anon

Posted: Jul 20, 2012

I began working for a doctor's office and we get referrals. Some of these apparently are entered by the doctor. It is the biggest mess I have ever seen. Sentences are run together. There is no punctuation. Capitalization is either nonexistent or incorrect. There are no paragraphs. The report is just literally words run together for a whole page. Other offices have canned forms, and they fill in a few blanks. The paragraphs and headings are inconsistent. There is no capitalization after colons. Every sentence is just a fragment. I understand we are all trying to save money these days, but this just doesn't seem like the best quality of care for the patient.

Agree wholeheartedly! - Trampled underfoot

[ In Reply To ..]
Actually, I'm acutely disappointed with how the records I transcribe turn out. Paragraphs are a thing of the past; everything is crammed together and a lot of the records have just one space between sentences. Absolute dreck. It doesn't look that way when I send it, but that's how it comes out on the other end. I'd be ashamed to tell anyone that was my work.

How does - sm

[ In Reply To ..]
that affect patient care?

The doctor reads the "highlights" and moves on. Missing periods, capitalization, paragraphing are only important to US :) We like pretty records, but pretty records aren't really necessary to treat a patient.

Important to us - On site MT

[ In Reply To ..]
It is not only to us that these things matter. Where I work we converted to VR and point and click a while back, it's a fairly large facility. In the first few months there were so many errors in the patient records that we had issues getting reimbursed by insurance companies. Now, many of our doctors dictate and we transcribe. They don't look quite as "pretty" as they used to but we make sure they are accurate.

Appalled! - TyperGal

[ In Reply To ..]
I agree with the last post. Does it affect patient care? Now it may, if there are incorrect entires, but that is for the doctor to check and obviously they don't. These are documentations, not a novel and that is why it bugs me when they insist on their BOB, guidelines, (this one kills me), "dangerous abbreviations." OMG, just type what they say and put it in some form of a sentence/paragraph. Who cares if two or 2 is spelled out??? Again, these companies are a joke and we are the ones suffering. I had a doctor spell a word wrong, I sent it back and stated so in the comment box at the end of the report. Every time I dictate for her and she wants that same word and she spells it wrong, that is how I spell it. Heelcord or heel cord, again who cares (I think that is the word, not sure, just an example). Sometimes, I think the posts on here get QA'd! :o)

If the doctor can't find the info quickly, - dnr

[ In Reply To ..]
they won't bother (gee there might be something important in the report). Part of what I (MTs) do is separate the report into paragraphs and headings so the information is quick and easy to find. If a doctor dictates findings and/or complications during an operative report so it is easy to find for the next doctor treating the patient.

Back in the very old days, without changing any information, we could make the doctors look good by making coherent sentences, and many doctors expressed their appreciation. Far too many doctors could not form a coherent sentence if their life depended on it.

Yes I do think it affects patient care if it is so - appalled

[ In Reply To ..]
crammed together and confusing and difficult and time consuming to read that they don't bother. With no punctuation it is hard to know what dosage goes with what medication, when anything happened, what is where and to what organ in an X-ray report. I think without punctuation and everything run together mistakes are unavoidable. More than likely, though, docs just won't put in the time to try and figure it out and I really don't blame them. Once again, I think most of what we type is just for documentation and to get insurance reimbursement.

Not to mention when they get sued. - anon

[ In Reply To ..]
These medical records won't stand up in court.

I wish I could scan one of these reports on here. - anon

[ In Reply To ..]
I don't think you are understanding what this looks like. It is almost like one of those word search puzzles.

It's time to take it back - winston

[ In Reply To ..]
As I've said in past posts, it is time for all of us to take it back. We have a good argument. The doctors DO care what their stuff looks like. It's the hospitals making the choice as far as transcription or VR. They opt for the cheap VR. We have to go to doctor's offices, one by one, and appeal to their sense of accuracy. These guys and gals went to school for 10 years or more to become doctors and they deserve not to have their careers destroyed by cheap hospital administrators. Once we infiltrate the doctor's offices, those doctors will see their insurance reimbursement increase because of the lack of mistakes and accuracy and will demand the hospitals give them what they need. It took only 10 years to get to this point, but if everyone on this board got one office job on the side, then two, then quit the bit company for three or four doctors, we'd be way too busy to sit here and bitch every day.

It's not about quality - although that's what they sell! - Runamok

[ In Reply To ..]
When I worked for a specialist clinic, I was appalled to find out they had 18 and 19-year-olds trying to transcribe into a "canned" report/letter. When they hired me, the docs thought they hit pay dirt. I got 1 doctor caught up in no time and his work was spelled correctly and looked like it was supposed to. The main office of this specialty clinic did not seem to care that the doctors spent a lot of time on the computer correcting what the ladies could not figure out or spelled incorrectly. They expected these girls to know medical terminology, schedule, answer the phone and transcribe.
After I was hired (actually to help schedule in another department and transcribe different tests), they asked me to help catch up dictation for all docs and teach their secretaries how to transcribe and tips on looking things up, etc. It was unbelievable that some of these ladies didn't even know how to "Google" and looking something up. It was very eye-opening for me. I loved the job but these ladies got very lazy once I arrived and I seemed to be the busiest person around (doing their transcription and my job as well).
The doctors I have encountered want their work to look excellent and they are very picky but it seems they are attached to bigger clinics/organizations and it's either the point and click programs, settling for under-educated secretary to transcribe and hopefully learn the terminology or just hire or do it themselves. I seriously don't even see them getting as much respect as they used to. It's about the corporations and the mighty$$$.
Just my observation, of course.

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