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

Help! I am confused - Mouse

Posted: Dec 01, 2009

I am not sure if I should ask on this board or not. I have read the chatter back and forth and .... oh my! I am still in school at Allied (not sure if it is considered a good school or not), but I am very confused about formating. I am sure in the real world the company that employs you will give you what format to use. However, in school I am suppose to know. Enough rambling! What I am confused about is the subheadings. As I transcribe the various practice transcriptions, sometimes the PHYSICAL EXAMINATION portion has the subheadings in all caps, with a colon, initial cap on the first word, and sometimes there are no subheadings and it is done in a narrative format no matter what the Dr actually dictates. Some dictations will have the subheading with initial cap, colon, initial cap on next word. I am supposed to know when to add headings when not dictated and when to drop headings when they are dictated! I ask the advisor and all I get in response is that it should be self-explanatory! I do not feel like I am beomg demse, but I am evidentually I am missing something! There seems to be no consistency. This happens on Chart Notes, H&Ps, Discharge Summary, etc. As I understand it, only on an H&P is it mandatory that the PHYSICAL EXAMINATION be in all caps, etc. All others can be put in initial cap, colon, initial cap on first word and done in a narrative form. I am counted off if I put P&E in all caps on some reports and counted off if I do not use all caps in other reports. It is frustrating to try to attain a 98% when I am not clear on how to do this format. If I format and the answer key does not it amounts to 4 errors per subheading! That is way too many errors!

Can anybody help? I know you are all seasoned transcriptionists; however, I would like any input that you have.

Oh, by the way, I do not bite back with criticism!

Help! I am confused - Mouse

[ In Reply To ..]
Ugh! Talk about proofreading! Please read past my oops.

caps - sandra

[ In Reply To ..]
Each clinic, hospital, doctor, etc will have their own 'rules' as to layout and capitalization. Some are paragraph form, others like caps, bold, etc. Maybe your answer is in your instructions ?

sorry, do not want to criticize,but from what you tell here...sm - what?

[ In Reply To ..]
I can already say that this seems not to be a good school. This is not important at all, every company that hires you will give you their specific instructions regarding headings, subheadings, the whole format thing, etc...

This is a link where you can look up how reports are formatted, maybe this will help you

MTsamples.com.

Good luck.

caps - do this

[ In Reply To ..]
Whatever you decide to do about your headings or no heading, at least be consistent in the way that you do it. As it has been said here, the company you work for will have their own format to us. If the heading is not dictated in real life dictation, then you would not type one in. Otherwise you just have to be able to tell what body parts would fit under what headings in the PE.

Good luck. Do they give you any assistance in finding a job later on? That is utmost importance, too.

Confused - Mouse

[ In Reply To ..]
Thank you all for your advice. I was sure that the real world was more consistent in its' formatting than the school. When I challenge a transcript, my advisor simply insists that there is a consistency as it is clear by the dictation! My feeling is that an introductory phrase has a comma after it or it does not, when the Dr goes on for 12 single spaced lines with "and" at some point you need to put a period and start a new sentence, if the Dr is dictating in a narrative form you may not need headings. I can go on and on. Still I will do as the school wishes in order to graduate. I have the chapter I am on and 2 more chapters to complete then I take the final. It is just very frustrating when I fail to make a 98% accuracy because I did not format or because (this time) the introductory phrase did not have a comma!

Maybe I am being dense, but one of the quizzes had a question: "The baby was laid momentarily on the mother's a) perineum b) peritoneum." By my experience neither answer is correct! The perineum is roughly 2" long and at the edge of a break-away bed. Tbe peritoneum is obviously not exposed. My challenge was answered by "since you could not put the baby on the peritoneum, the only other answer is perineum. We just needed to know if you knew the difference." What am I missing here?

Oh well, I trudge on. My consistency on my transcription submission seem to net me a 85% to 90%, but at least the spelling and verbage is correct! I am having troubles with the commas, though. As someone stated in another part of this site, commas do NOT always go where the pauses in speech are! They should go where they are grammatically correct!

Help! I'm confused - gourdpainter

[ In Reply To ..]
I really can't speak to the issue of whether Allied is a good school or not. I only know of one person who attended that school. She is back in college now.

As to the headings, I personally feel that there are many more important things that need to be taught as each hospital has it's requirement for formatting. Formatting is the easy part. What your employer evetually requires may or may not be what your school requires. Since your objective is to pass the course at this point, I would make a phone call and INSIST that they clarify what they expect. If you are eventually able to land a job, trust me, the employer won't be paying attention to formatting other than whether it demonstrates that you know what you are doing by using one of the many formatting possibilities. As has been suggested here, you can get an idea by going to the website someone posted but that won't tell you what the school requires. They took your money, make them earn it by answering all your questions to your satisfaction. That's what they hired on to do. If the instructor doesn't answer your questions don't hesitate to go over his/her head.

Well said Gourdpainter - BEST ADVICE YET TO OP! nm - Hiya

[ In Reply To ..]
nm

So soon they forget.... - Invisible MT

[ In Reply To ..]
How soon they forget we are PAYING them for a service/education. Milk them for every drop of knowledge you can get out of them!!

Perineum - Rainbo

[ In Reply To ..]
Perineum: The area between the anus and the scrotum in the male and between the anus and the vulva (the labial opening to the vagina) in the female. This is the area that is cut (episiotomy) to assist delivery during childbirth.

Did your school not give you a Book of Style? - Typing-away

[ In Reply To ..]
If you are at the end of your schooling and you don't know the difference between a discharge summary, a office note, and a history and physical report IMO they ripped you off. This was something I had to learn early in my schooling and they continue to emphasize. Look at the Book of Style and the reports are towards the back of the book.

Book of Style - l224

[ In Reply To ..]
You know, I purchased the Book of Style 3rd edition and found that I haven't used it near as much as I thought I would. I've worked at 2 different places so far and they both have their own rules of formatting, etc., and a lot of those rules are different than what the Book of Style says. So I go with what the employer wants over the Book of Style or even what I was taught in school. It all really comes down to what the employer wants and expects, I think.

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