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

Client specifics should be less specific!! - My Vent Today

Posted: Jan 13, 2010

Why, oh why can't all the dictators on one account use the same format????!!!!!

Dozens of doctors on the same account and they all want different styles. Some want headings capped, some do not. Some want bold, some do not. Some want them underlined and some do not. Some want PHYSICAL EXAM, some PHYSICAL EXAMINATION, and then some EXAM. Followinig on down in a note, you can just imagine how many differences there are with each dictator.

These guys are all in the same medical practice. Why is this necessary? Why can't it all just be one standard format? Since you simply cannot remember all of them all of the time, you have to constantly look them up for a couple of people. So much emphasis is put on this that I believe it uses up valuable MT time and makes us less productive, which does not seem to matter to anyone except us.

I know it happens all the time. Just wanted to vent about it today. I'm done.

I agree. I think it distracts us from the medical - sm

[ In Reply To ..]
stuff that really matters.

format - anon

[ In Reply To ..]
Amen! Some of my accounts are bordering on insanity. Do this, don't do that, Dr. so and so wants this, blah, blah, blah. It's mind boggling when you have to constantly refer back and forth for physician specifics, especially when you don't transcribe them every day. I remember the good old days on some accounts where every dictator got the same transcribed format no matter what their individual preference might have been. (Sigh) I really hope that in some way healthcare reform will force a more consistent standard form for the records.

Agreed. One thing that helps, though, is to -- (see msg) - CM

[ In Reply To ..]
put an entry into your expander for each doc and their style quirks so that when you start a report for them you can call that up first thing and have it put in their preferred headings, display notes to yourself about their other demands, etc. It beats having to look them up each time when you can at least have it display when you start a report for them.

CM - anon

[ In Reply To ..]
great suggestion!

I once had a hospital with 115 pages of account specifics, so -- sm - CM

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-- I had to do that just to keep my sanity. It was a 5-hospital system, each hospital with their own specifics, and practically every doctor at each hospital demanding their own quirky things. It was horrible.

Great idea! - That the way to do it!

[ In Reply To ..]
:)

It doesn't have to be like that..... - sm

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I took on a group of physicians that called me years ago wanting me to do their transcription. Once talking to them about the specs, they ALL started acting ridiculous wanting this and that, and just silly junk. I was very blunt about the situation and told them if they all had to have such time consuming specs, then I would charge for additional time to do all this; otherwise, after looking at their prior transcriptions, it was obvious (I got this also from the staff) that they were getting all this hand holding and acting like babies. So, basically, I told them all these different formats made no sense, it made the records look inconsistent from doctor to doctor and frankly, were hard to follow. Cap this, don't cap that, bold and underline EVERY test mentioned in the report, don't underline but BOLD every test....it was absolutely asinine.

I was so sick and tired of watching these guys being babied to no end that I simply said here are several formats to follow, pick one they could all agree on, and let me know if they needed me. After the staff discussed the "additional charges" for all these ridiculous specs, which they agreed even they found distracted from the report, the office manager called and said they agreed to a particular format and when could I start picking up (yes, back in the days of tapes).

Since so many docs think our time is completely invaluable and all we do is sit around basking in doing their transcription, I had had enough and these were the formats I came up with....plain and simple. If they wanted more, they paid for more, just like they would charge for more if they spent more time with a patient. I let them know I didn't run a charity, I worked hard and LONG for my bucks, and I wasn't going to be taken advantage of.

The problem is these MTSOs just go with whatever to get the accounts and bend over backwards to appease these guys, as if the ICs have nothing better to do. It does use up valuable time and is MUCH less productive. I have found MTSOs that don't go for all that up front, they keep things as simple as possible for everyone, and they don't seem to have trouble getting clients.

And there's MY vent! LOL!!

Your post is the answer. Always has been. I wonder -sm - Zircon

[ In Reply To ..]
when MTSO's will finally realize that all this blind, sheep-like following of "the rules" in BOS is COUNTER-PRODUCTIVE. That it's morale-deflating, idiotic busywork, and that 99.9% of the time it has no bearing whatsoever on patient care, or what constitutes a proper medical record.

Instead of worrying about ridiculous formats, hanging indents, block form or indented form, bold, underlines, capitalized or not, everyone, docs included, should mainly be concerned with documents that:

a) Are dictated carefully so they can be interpreted correctly.

b) Have the proper demographics, numbers, etc. entered correctly, so things don't have to be sent back to be straightened out, or sent through with holes.

c) Are SIMPLE, clean-looking, and EASY-TO-READ. The latter is a big thing that for the most part BOS and the MTSOs seem to be ignoring completely. When the docs actually read a report, whether it's on the PC, a printed report, or in a letter, they want to be able to skim it and go directly to the meat of what information they need. Anything that squeezes the document together or chintzes on spaces or punctuation merely makes the document just that much harder to gain valuable information from quickly. When will MTSOs and ADHI realize that SIMPLICITY is key? NOT volume upon volume of useless "rules" that have nothing to do with the purpose of a medical record: To provide INFORMATION.

d) DICTATED and/or KEYED-IN CORRECTLY! I can't emphasize that enough. Do it right the FIRST time, docs! You want it yesterday, but you key in the wrong MR#. Or you accidentally merge 2 similar reports on 2 different patients into one potential legal nightmare. If you're sending copies, then take 2 seconds and give the bloody address! Otherwise, it goes back to QA for straightening out. Even in your own hospital, please at least take 2 seconds to slow down and pronounce consulting, copy-recipient, referring or resident doctors' names CAREFULLY. You don't need to spell them. We'll look them up. But if we have no clue, even, as to whether the name starts with a vowel or a consonant, then most likely we're going to leave it blank. Gums up the works, dudes.

e) I'm with you, I don't believe the doctors give a U-no-wat whether we call it an optic disk/disc or a spinal disk/disc. Or whether we type AM or a.m., MiraLax or MiraLAX (the way it shows on the bottle and on their website!) What's REALLY important is:
- Is the demographic information correct? Is it the correct patient?
- Is the report clean and legible?
- Is it easy to read?
- Does it look like it was written by an MD or a PhD, or a complete idiot? I for one am tired of my work having to look like the latter, simply because it was:
(1) Dumbed-down for the sake of "conformity" with ADHI, VR, or the Indian workforce.
(2) Edited by kids who are working for pennies, and on production, and who need to find lots of "errors" in order to justify their positions.
(3) Or looks like it was typed by an orangutan because of cheapo transcription platforms that don't recognize certain basic punctuation marks, underlines, bolds, italics, or tabs. If they take much more away from us in the way of word-processing tools, then we might as well go back to using a rock and a chisel.

You're 100% right! Great post! - nm

[ In Reply To ..]
nm

These issues should be addressed in the BOS, not going back and forth about hyphens and commas!...nm - BOS

[ In Reply To ..]
nm

Silly, docs do not care a fig for BOS - most are unaware it exists

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I'd settle for everyone in a single facility agreeing on uniform report styles, without Dr. S having to have something really special just for him because he has issues.

that's what I am saying, there should be uniform rules...sm - rules

[ In Reply To ..]
laid down in a BOOK, not only for a hospital, for the whole US, so that MTs can easily jump from 1 place to another, with all the same format rules!

I know, I am dreaming!

True.....docs couldn't care less AND BOS is nothing but - a money making gimmick for someone else!

[ In Reply To ..]
nm

account specifics - tired MT

[ In Reply To ..]
I think there should be a standardized format nationwide and then if the hospitals want something different they should have to pay for differences in the format.

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