A community of 30,000 US Transcriptionist serving Medical Transcription Industry
I am not allowed to think for you!
Sincerely,
The Typing Zombie
I have done three extremely long H&Ps dictated by the same nurse practitioner and OMG. She has dictated the entire physical exam and in the middle of dictating the extremities, she says, "He has been wearing O2 2 liters nasal cannula during the daytime hours." No, go back up and put this in under vitals or respiratory. Just, "There is peripheral edema. Pedal pules are normal. Skin is intact. He has been wearking O2 2 liters..." Then she says "his speech is normal with no slurring. A little muffled when he's wearing his CPAP mask." Well yeah! Do we need to include that in the physical exam REALLY?!!
Sorry, I'm just hanging on by a very thin thread today with crappy dictation and just stupid, STUPID dictators who cannot seem to put a coherent sentence together to save their lives! "He has TED hose worn." And I'm typing VERBATIM so take that QA! Have FUN!