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


Article - EHR notes and cut and paste - documentation problem


Posted: Jun 16, 2010

Excerpt:

Free-text narrative will often be superior to point-and-click boilerplate in accurately capturing a patient’s history and making assessments, and notes should be designed to include discussion of uncertainties.” (italics DMCB).

Link:

http://www.kevinmd.com/blog/2010/05/ehr-notes-cut-paste-documentation-problem.html

EHR - nan

[ In Reply To ..]
Maybe there is hope for us afterall. Wow, look at all the money they have spent on garbage when we told them it wouldn't work and we told them for nothing. LOL

It always works that way. Time sorts things out - The experts are always wrong

[ In Reply To ..]
It always works that way. The experts always say what is going to happen. They are always wrong, but that doesn't keep them from coming up with another theory next week and the week after that. Nobody knows exactly what things will look like 10 years from now and if they say they do, they are either hallucinating or being untruthful.


Similar Messages:


Excellent Article About The Deterioration Of Notes For Patient Care
Sep 19, 2014

I have always hated it when the doctor crams in every disease the patient has in the first line whether or not the list is relevant to the chief complaint.  I can't think of anything more pointless than having a PA or resident dictate discharges when all he or she does is lift the consultants' impressions and plans and then plug in his or her standard "vital signs remained stable and the patient was discharged in stable condition."  They just chant thru it, as fast as possib ...


Cut And Paste
Jun 05, 2013

I really need someone to answer this. I have been accused of adding spaces to my documents, but my argument is that cutting and pasting the doctor's templates in a document used over and over (changing any parts he wants changed) is adding spaces. I did not do this on purpose. Has anyone ever had this type of issue before? Or am I alone? ...


No Cut/paste Workaround?
Oct 03, 2012

So is it a HIPAA violation to copy text from a sample by the same dictator, paste it into Notepad, then cut it from Notepad & paste into your document?  ...


How To Cut And Paste With Same Font As The Document?
Nov 02, 2009

Occasionally, I cut and paste an address of a physician into a letter document, and it pastes with a different font than my letter. I have to highlight that portion and change whatever I pasted in my document to the correct font. Is there a way to make that faster? Slows me down. TIA - Janet ...


Meditech Copy And Paste
Nov 11, 2009

I'm just training on an old version of Meditech, I think it's V 4.5.  I don't see any way to block text or copy and paste.  My trainer isn't familiar with this version, either.   Does anyone know how to do it?  Thanks! ...


Copy And Paste In Editscript
Aug 19, 2011

I used to be able to copy and paste with no problem, but for the last couple of nights I have not been able to paste.  I have no problem when I close the program and just use Word, just won't work in Edisscript.  Which leads me to believe they did something to stop us from copy and pasting.   Anyone know how to fix this?  I have Word 2007. ...


You Do Copy And Paste From Job Search Don't You
Oct 16, 2012

everyone is doing that right? ...


Copy And Paste In Email.
Jan 22, 2014

How do you copy and paste in World Client.  For some reason, it won't let me use that function.  Is there some kind of a trick?  ...


Tried To Cut And Paste But It Didn't Work - Could You Explain Again
May 24, 2010

The first report I tried this with, I was able to copy into a Word document.  The second tiime I tried to cut and paste, the first report kept showing up.  The third time I tried it, the first report copied over the report I had just transcribed and I lost the transcribed report and had to do it all over again.  What am I doing wrong.  Like some of you, I'm being sooooo careful, going over my reports twice before sending them in, and they're coming back with a bunch ...


Copy And Paste Into Meditech From Word?
Jul 29, 2010

I want to type in Word and paste into MediTech, which is hard to type in. Does anyone know how to do this?  Right now the text I "paste" onto the clipboard in Word does not paste into MediTech.   Thanks ...


DocQscribe Copy/paste Question
Mar 24, 2011

I have noticed suddenly today I am unable to cut and paste (e.g. doctor names, street, addresses, Rx) from DocQscribe to Google.  Everytime I try this function it says "DocQscribe Internal Clipboard Text".  What the heck!  By right clicking, it is saving me from having to "retype" everything that I am confirming.  Has anyone else run into this? ...


Cut & Paste MS Word 2003 And Editscript
Jan 11, 2012

Trying to figure out the proper setting.  When I copy a reference and want to paste it into Editscript (MS Word 2003) it pastes the original format, changing the font, size, etc.  I would like to paste it so it matches my document.  Do you know the setting and where it is located?  Thanks so much ...


Is It Efficient To Transcribe In Word, Cut And Paste Into Another Software?
Dec 12, 2009

I have always worked in Word or an equivalent of, however, I have one account in another program that does not work well with my Instant Text.  The account is actually quite good and I could produce much more if I could take advantage of some form of production software.  Has anyone worked in Word and then cut and paste the work into the software and it was successful?  I can use Instant Text, but many of the functions do not work, which only makes it more confusing whe ...


How To Copy&paste A Page Made Uncopyable :)
Jul 19, 2013

Printscreen usually works to copy a screen image, and you can paste that from the clipboard to any program, like Paint.  When you cannot use the "Print Scrn" key to copy, just open up your task manager "control+alt+delete," and when that pops up THEN you can "print scrn and paste with the report in the background. All those bogus FIESA mistakes QA has been assigning to me are coming back to them big time with proof those were not my errors.  ...


Medisoft EMR Remote User Problem - Cannot Paste Into Pt Record
Jan 24, 2014

I am hoping someone is familiar with Medisoft program.  I just obtained a position as a remote user for an office that uses Medisoft.  Today is day one.   There are two other remote transcriptionists.  The way they are doing this is to transcribe the dictation in word and then cut and paste into the various sections in medisoft.   They are able to cut and paste, no problem.  I am unable to paste into the patient records from my Microsoft Word document.   This ...


Need Simple Word 2010 Macro For Copy/Paste
Feb 14, 2014

I've been using Instant Text for years but realized that there are probably quite a few macros I could create in Word 2010 to make certain repetitive commands a lot easier for me.  I know the basics of creating a macro in Word but cannot for the life of me figure out how to create a macro to do this: I want to copy text,(i.e. from a Preoperative Diagnosis) and have it pasted into the next line after the heading Postoperative Diagnosis when the dictator says "same." I tried recording ...


HELP!! My QA Notes Are Not Going Through!
Mar 29, 2010

I just got another email from my QA super saying that I should have left a QA note for a report, however I did. This is the third time this has happened to me. I have called support and they say there is nothing wrong, but I only work 3 hours a day (other full time job during the day) so I remember the reports that I type. Is this happening to anyone else? I've am already on probation and this isn't going to look good obviously, but I don't want to sound like I am making ...


Op Notes
Apr 19, 2010

When everything after heading is numbers (such as IV FLUIDS 1500 ml, EBL 2000 ml, etc.), do you spell out fifteen hundred milliliters and two thousand milliliters?  That is how I interpret the rule of not starting a sentence with numerals, but it really does cloudy the waters and make the op note less easy to read.  ...


QA Notes
Jul 07, 2012

If you insert a QA marker, how do you close the QA note box at the bottom?  Ctrl+C doesn't work.  I have to manually click in the report to get it to close.  Is there a shortcut? ...


To Those Of You Using MQ's Lotus Notes,
Oct 12, 2009

Have you performed your upgrade yet, did you have any problems with it, and are we required to do it?  ...


QUESTION ABOUT OP NOTES Sm
May 24, 2010

I used to specialize in op notes but for the past 3 years I have not found a company where I could solely specialize in op notes so I have kinda gotten rusty.  What I have noticed in the past 3 years is the few op notes that have come my way are by the worst ESL dictators.  Is this a trend in op notes now? Does it seem that they are done mostly by ESLs?  I was just curious as to other MTs recent experience with op notes, especially those who work is mostly op n ...


Would Like To Compare Notes With Others New To MQ,
Apr 16, 2011

especially if you're on a southwestern account and doing editing for the first time.   I started with MQ last month and feel very discouraged, mainly for all the minor negative feedback I'm getting.  I'd like to know how the other new employees are doing so I can get a sense of where I stand.  I keep thinking any day now I'll get a notice I'm fired.   Email me directly and dish it out. ...


Do YOU Get More Lines Doing Op Notes?
Mar 07, 2012

I had op notes added to my q last week.  My line count has went up quite a bit due to the doctors using templates for a lot of op notes and the fact that they say the same things usually.  Anyone else end up with more lines doing op notes?  ...


Surgical Notes
Oct 15, 2012

Did anyone who applied for the Surgical Notes position get a reply? ...


Live Notes, Anybody?
Jun 08, 2013

I have a chance to get in with an MT company that also offers their ICs a chance at live note taking.  It doesn't pay too good, though, less than what the standard reports pay per audio minute.  I have never done this.  Can someone explain to me how it works?  I have heard that "live notes are typed in one pass."  What does this mean? ...


Pend Notes, Etc. How Far Do You Go?
Dec 05, 2013

Did anyone else get the speech again about pend notes being too long? I can understand why they want us to be "professional" about it but if there is an ODD problem (and there always is!), how am I supposed to tell them? Today, it said referring physician was Alan so-and-so, so, there was no ALAN So and so in the list so, I had to leave a blank BUT, the HPI mentions Albert So and So. Um.... okay, but still no Albert so and so.... Then, back to Alan, so and so, then at the end, copy to Albert ...


How To Know Which Notes I Read
Apr 17, 2015

Hi all, I used to be able to tell which notes I read on a forum, because they showed up in a different color. Something got switched on or off, and now I have no idea which notes I've read, and which ones I haven't. I use Google Chrome. A lot of things are different in Google Chrome than IE, and I don't know if this is an IE vs Chrome issue, but if anyone uses Chrome and knows for sure how I can fix this, please let me know. Thanks! ...


Question RE Ortho Op Notes
Jan 05, 2010

Hi, When transcribing ortho op notes, many times the procedure is very very long.  Example:  Right knee arthroscopy, subacromial decompression, capsular release, synovectomy, etc. Do you list these and number them or do you keep them in paragraph form?  Thanks. ...


Where Have All The Op Notes Gone At Every Company? I Can Go Days For My
Jan 10, 2010

mn ...


Clinic Notes = No Money?
Apr 16, 2010

I lost my primary accounts recently and was switched to an account where most of the jobs are really short clinic-type notes (less than a minute).  This pay period, my paycheck will be over $200 less than it was when I had my primary accounts, and I'm barely making my minimum line counts.  I've been doing this job for a long time and have always had really good line counts before.  I've been feely really down in the dumps like maybe I've just kind of lost ...