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M*Modal

Shame on that auditor - Dying breed

Posted: Nov 7th, 2016 - 8:37 am In Reply to: I was marked off on audit for adding heading - sm

This should be the kind of thing we can challenge and win. If it is not verbatim, we ARE supposed to add in headings and we are free to add in paragraph breaks if it makes the text clearer. True, our task is to make minimal changes and we don't have to add in nonstandard headings, but the art of MT work includes the ability to know when a change can be made that does not affect meaning or change the way the doctor talks, you know? So if he says "patient is here," we don't add "the patient" because that's not how he/she talks. But we divide the report into at least the minimal, basic sections for formatting because that is necessary and expected.

I too have had auditors lately add back in things like "include." We were always told to remove them because they are unnecessary, unless they were important to meaning, i.e. "Current" medications, etc. So now I tend to leave them in because what difference does it make? And I don't want to hear about it.

But in no case should anyone be telling us to leave out important headings in an H and P or Discharge Summary where the report is less organized without them! And especially under physical exams. Of course the doctor is going to forget to dictate "extremities" once in awhile, or "general" or whatever. They trust us to add those in. It's what we do!

That is disappointing that an auditor would have said that to you when you were doing it right. No wonder everyone is doing this differently now and the reports are looking so disorganized. That is even sadder!

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