Agree it is a power issue - MT Posted: Dec 15th, 2017 - 8:54 am In Reply to: It's ridiculous that the medical record format hasn't - been completely standardized.
I have worked onsite as an MT and in management onsite and as a manager in a service. I can tell you the account specs are a power trip of the head of QA or the lead transcriptionist. The highest person in the MT department who has hands on. That person. And most times the standard stuff are all the docs and Joint Commission expect. Of course dangerous abbreviations, etc. are important. Joint Commission is more important than AAMT or whatever it is called and their BOS even acct specs each head of MT department make. Joint Commission is the be all and end all. Aside from that good grammar and whether or not the docs speak correctly so as to avoid errors. HIPAA security rules are important. But put that aside which is all very minimal, the acct specs are the head trip of the lead MT or head of MT department at the hospital. Get these people to change their mind is like asking hell to freeze over. Won't happen. BTDT. It's easier to ask the docs to dictate correctly which by the way is the job of the head of the MT or lead MT and they won't do that either. Just a little inside info.
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