Does not have chest pain vs no chest pain - At what point Posted: May 31st, 2021 - 12:42 am In Reply to:
would you change the above phrase to the shorter one? Wouldn't you have to listen to the whole dictation corresponding to the chest pain in order to better understand the context of why the doctor may have chosen to use the longer phrase?
If the doctor is examining a patient and asks whether chest pain is PRESENT upon exam and the patient says, "I don't have chest pain," then it would be a far more accurate descriptor for the doctor to dictate the patient "does not have chest pain" within the context of the exam.
If the doctor later asks the patient whether they've ever experienced chest pain and they say, "no chest pain," then I'd transcribe that as dictated too, because it corresponds to the question asked.
I think those small details can make a big difference. That's why I'm completely against changing or omitting anything dictated by the doctor from the final report. After all, it is their dictated report in their unique style, word choices and all. Unless there's a discrepancy, then that could be flagged for QA or the doc to recheck, etc.
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