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


Re: OB reports - starfish1975


Posted: May 17, 2010

I know I will be asking many questions in the coming weeks since I am going to be taking a more active approach to studying for the second part of my final. Can anybody please tell me where I can go to get more info on OB reports online? Some of the stuff that the doctor dictates is so hard to figure out since I am not familiar with the OB terminology at all. For example..here is the physical exam section of the report (keep in mind I have flagged certain sections). Here it is:

 

 

Abdomen: Soft and gravid, slight tenderness to palpation in the suprapubic region. Extremities: Slight peripheral edema. DTRs +2. Cervix: Dilated to 1 cm thick. Mid position is soft. Presenting part ballotable. Bishop score: 4. (Bratlav) exam: Negative. HSB cultures done. Realtime ultrasound revealed (A05) 13.9. (SM) (revealed weight) 2889 grams.

 

I am having trouble coming up with what "Bratlav" exam is.. or the rest of the paragraph after it. Please help. i really want to get ready for the transcription portion a second time around of the final so that I finally pass and get on with life. Thanks ladies.

 

OB help - annabanana

[ In Reply To ..]
Bratlav has me stumped right now, it's probably something simple though. Here are a couple of corrections:

Cervix: Dilated to 1 cm, thick. (You need that comma there. The thickness has to do with effacement and is a separate measurement from the dilation.)

HSV cultures done.

Realtime ultrasound revealed AFI 13.9 cm, revealed weight 2889 grams.

Thanks for replying annabanana - starfish1975

[ In Reply To ..]
Thanks for replying. I found out that Bratlav was "Bright light"... I am still fuzzy on OB reports but much better on others. Hopefully I will get the hang of it. Thanks so much again. :)


Similar Messages:


Prefer Short Reports Or Long Reports? Sm
Jun 13, 2012

Hi all. I was just wondering what other MTs prefer...little short reports or very long reports? Do too many of either affect your line count (and therefore your pay)?   I definitely prefer very long reports!  ...


Long Reports Or Short Reports?
Jul 15, 2013

Am i the only one that just hates the long ones? And by long I mean anything over like 4 minutes.  I love progress and ER notes!  ...


ER Reports
Nov 21, 2009

Should ER reports be a priority? I work in-house and this week our transcription department was ordered to type all ER reports as priority, before any inpatient or radiology work. The order came from the ER committee to our department head and down to the transcriptionists. Any thoughts on this? ...


Looking Up Old Reports
Mar 07, 2010

does anyone know if this dqm lookup reports is working adequately.  It seems like a whole lot of trouble to find any. I know this was discussed down below about where the heck is dq main menu and search.  I tried looking up by dictator and its a waste of time as there are not any old reports there.  Thank you to any help out there.  ...


Anyone Know If You Can Look Thru The Old Reports When
Mar 09, 2010

you are not clocked in and working in Docuscribe?  ...


QA On Reports
May 11, 2010

Can anyone tell me since MQ has gone with the Swap Board and First Time Right, and we are sending reports, etc.  Have you had more frequency of being followed by QA?  I was just wondering how that works?  ...


Can You Look Up Old Reports At Your Job?
Jul 28, 2010

I used to be able to at my old job last year. Now I can't do it at my new job. I asked and was told it is because of HIPAA. Can you look up old reports at your job? It sucks that I can't do it. It would help a lot. ...


Oh, No. My Op Reports Went ASR.
Aug 11, 2010

I love doing op reports even with the mandatory standards as I can insert my expansions and am very familiar with them (when I get my primary).  Now it's all ASR and I have to use those standards.  I have to cut and paste, cut and paste, cut and paste, lose my skip markers, can't use my expansions AND I now get paid less for the reports.  Any suggestions? ...


Too Many Reports To QA
Dec 03, 2010

I just was spanked for sending too many reports to QA.  I sent ONE to QA in the last 3 months!!!  HAHAHAHA!!!  ...


QA Reports
Apr 13, 2011

Anyone out there who works remotely for a hospital.. can you tell me how your QA is done.  Wondering if most are like my employer.  Our QA is done sporadically.. maybe twice  a year.  We get a stack of reports in the mail that may be 6 months to a year old.  Our editors follow none of the standards our department has set up, and usually just whatever they feel is wrong, is wrong.  Also, we can't go back and access the voice when we are looking at the errors to ...


Where Are My QA Reports Going??????
Jan 30, 2012

I checked my work 1 hour ago.   Just checked again and all 6 reports with 100% QA are gone.   Three new reports, one with crappy grade (missed a heading), and 2 100% reports now show.    How can you maintain QA with reports flipping in and out??????  This is Nuance.  ...


Does Anyone Keep A Log Of Reports For The Day?
Apr 17, 2012

Hate to waste the time but Im gonna do it today..I have several jobs that I put through QA for terms that I really should know but cant find and I never get them back from QA with fixes...Just wondering, we were victims once before and no matter how much OT I work the counts never seem to go up much... ...


Reports
May 28, 2012

Have you ever noticed that as soon as you are proficient in an account you are switched to a new one???? AND in certain reports are required to use a standard even though it is an SR report SO you are doing straight type in an SR report, being paid at SR rate.  Something doesn't seem quite right or fair. ...


IME Reports
Jul 05, 2012

Can someone explain to me the expertise required to do IME reports as it compares to acute care hospital work? TIA ...


Reports Going To QA
Oct 16, 2012

If a report is really bad, cant even find the patient- when it is uploaded and we have a note to QA, is that report sent to be charted and the doctors, or does QA fix it, whatever, and THEN is sent? Do we do anything different so it does NOT get sent to the client first? Thanks you guys!! ...


5 Day 5 Reports For 98% On QA?
Jun 19, 2013

I was speaking with a friend of mine and he just got the last bonus and then was told he was not supposed to get the bonus because the hospital he works on doesn't get bonuses so not to expect another one and then 2 weeks ago they put him on 100% QA 5 reports a day for 5 days and then extended it for another 5 days because they said he had 98% though on the bottom of his timecard is showing 99% and the feedback has been 99%.  What are they trying to do now?  He just got a call fro ...


VR Reports -
Sep 03, 2013

I thought it was just me.  I've posted before asking for any hints to get my VR reports to go faster, but spending so much time "editing" these reports it's going soooo slow and don't know how to go faster.  Is this common with other MTs?  Any helpful ideas are appreciated. First line will be what the doc said - after the dash what the system put (and this is just one report): 55-year-old - nothing was typed she points - she reports he points transumbilical - tr ...


Looking Up QA Reports
Sep 06, 2013

How do we look up reports that have been Q/A'ed for our audit?  I thought I knew how, but I cant get anything with the numbers I have been given to come up.  Thank you. ...


OLD Reports
Dec 11, 2014

In the past 3 days I have transcribed reports from as far back as January 2013. Ridiculous is all I can say. 3 reports today were from June of 2013.  No wonder the backlog is twice what it normally is and they have to offer that incentive. We shouldn't get yelled at for something totally out of our control.  ...


I Have A Lot Of QC1 Reports....all Over 99% And Most 100%
Dec 15, 2014

until I realized that NONE of those count as far as my pay is concerned...not a one of those 100% reports matter not one iota....they are not "post-audit" reports..... Then I look in FIESA again and realize there is ONE post-audit report and one alone....and IT has a 98.9% score!  (for what THEY say was a "major" error----I have a beef with that but what can I do?)... So I am starting to see how we all are basically at the mercy of whatever they want to do.....Patient Safety Plan MY ARSE ...


QC Reports
May 13, 2015

Numerous times over the last month, I have noticed reports that I did NOT pend to QC for any issues are being reviewed and going towards my 10%.  I have had at least half a dozen already.  There were no blanks or issues with them whatsoever.  I keep track of all my reports and which ones I send to QC and to the client.  Then they wonder why people hate this fricken place and are dropping like flies!  This company is dirty and wicked all the way.  I would fight it, b ...


Radiology Reports
Oct 18, 2009

Does anyone know what the average daily income is for typing radiology reports at 0.09 line?  Thanks. ...


How Many Reports Do You Type In A Day?
Nov 07, 2009

I was just wondering how many reports on average you type in a day, and how long are they? Are you full time or part time?   Thank you! ...


I Just Hate These Reports
Nov 10, 2009

I'll leave out specifics  - just that patient had fetal intrauaterine demise and she had to delivery the baby vaginally.  I went thru 14 years of infertility without any results and I'd rather go thru that again than what this lady just went thru.  I feel so awful for her. ...


Regarding The Old Reports Used For Training At MDI
Nov 25, 2009

I believe that these are old reports used for training, but I don't think they are training new MTs on the account.  I believe they are training VR.  Someone mentioned below that it doesn't make sense to pay someone to do old reports that have already been done, and I agree with that also.  Plus, think about the fact that MDI had never, ever trained like this before, even after receiving email after email asking where all our work was going and why we had no work.  ...


Looking At Old Reports In EditScript
Nov 27, 2009

I recently upgraded to EditscriptMT 8 from verson 6 and now find I cannot look back at old records as I used to do and check for familiar phrases, medication lists or other information.  Does anyone know how to look back at previously transcribed/edited patient records in EditscriptMT verson 8?  Thank you in advance. ...


Question About Changes On Reports.
Dec 30, 2009

Today I went back to look at a report that I did yesterday because I had the same doctor dictating on the same patient and wanted to check something.  The report had been changed in ways like operating room to Operating Room, we are not supposed to capitalize per client profile, and numbers to #'s which I have never done.  My question is this report was not in QA feedback and if I had not looked at it I would have not known of the corrections so is there a way to check changes to ...


Getting Depressed Over Reports
Jan 03, 2010

I find that lately I am feeling depressed over the reports I've been transcribing.  Maybe it's because it's the holiday season and I can't help but feel badly for these people who are so very sick (I do acute care).  Lots of oncology these days, for some reason.  I wonder how MTs who transcribe for childrens' hospitals or cancer clinics handle it.  It must get to them. ...


Explain This To Me! Reports Are Gone.
Jan 06, 2010

I was working tonight.  Just me and someone else on the system on my primary account, like always.  The only difference was 67 reports (double the amount) when there is usually around 30 reports every night on the primary account.  I worked for 2 hours.  Got off for an hour and came back on and NOTHING.  I did not get my primary.  How strange?  I go back and look at my primary account and it shows 12 reports are left out of 67 reports in one hour ago.  I ...


Reports Not Showing Up
Feb 05, 2010

Doesnt look like the reports are rolling around in DQM for some reason. ...