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

General Rant - Ann H.

Posted: Jan 11, 2011

Have you ever noticed than when a dictator tries to adopt a "conversational" style of dictating, that it is very hard to try and figure out what's being said? They start and stop several times so that you can't remember what the original line of dictation was, plus they add "you know" every other sentence. I DON'T KNOW!!!!! My account is a verbatim one and so I figure out as near as I can what he's saying and then send it through.

As patient I wouldnt want MT "figuring out near as possible" what - is dictated. Would rather they send with blanks. n

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A qualified MT is supposed to "figure it out." That's what we do. - ...

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And if you think that doc is gonna remember what he/she dictated and then fill in that blanks, you're mistaken.

Qualified MTs are medical language specialists. We interpret what they're dictating and transcribe it, all while correcting their enumerable mistakes. Furthermore, no, you wouldn't prefer a blank. If you got copies of your records and the report was riddled with blanks, your first thought would be "who typed this," and not "why didn't the doc fill in the blanks."

You want verbatim? ASR (speech recognition) is verbatim. Just check out the ASR funnies in the Comedy Stop forum to see how well that's working out.

Totally disagree. MT suppose to transcribe what she hears. If cant hear, blank. If unsure of - what is dictated, blank. You are NOT the SM

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dr that saw me, you are to get his words on paper. No guessing, no "idea what he MEANT to say", no I think this is what he said. Any doubt, blank. My name is Jane Doe. If you get MY report, do not assume you know what dr is saying/meaning, blank it!!

The job varies. Officially everywhere it's as you say, - Anonny

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a good defensive position on the high ground by the employer, but in practice most places I've worked a good MT is valued for ability to fill in blanks, exercising dependably good judgement in figuring out what must not be guessed at. I've been doing this for years and literally cannot remember a time when anybody came back questioning my work--except once from bad QA in another company (the kind that give QA a bad name), among a report peppered with such disagreements as whether a semicolon or sentence split was appropriate, her own incorrect guesses, etc. You know. In three years I've never heard from QA at this one for this sort of thing. Also, not all of us work on verbatim accounts by a long shot. None of mine are.

I just minutes ago finished a classic example of the value of years of experience in figuring out what a husky-voiced and rather sloppy dictator speaking in a low voice said. Were all connecting words exactly the ones he chose? Highly doubt it even though I gave it my best effort, but I do feel good that they conveyed what he said.

You can do "gray area" MTing on others, but on MINE, - just put down what you KNOW he said. nm

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Gray area MTing-sm - are you kidding me

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What, please tell me, is gray area MTing? What properly trained MT makes a decision on gray areas in dictation. If you don't know, you don't guess or put what "you" think it should be. When in doubt - check it out.
Prime example:
I was doing a MRI followup on a prostate cancer patient. In the body of the report the doc said "no new abnormalities since the prior exam of ------". In the impression he said: Lesion unchanged in size since -----. I did not have this doc's phone # as he was a corporate administative doc reading to catch up a back-log we had. The person I was working with decided to play games and not give me the doc's phone # (we were allowed to call the doc's). So I said pull up the prior report on your computer and let's see if anything was there last exam (gray-area MTing?). Nothing there but the other person said "Oh, Dr. so and so read the last one and she just missed it". WRONG--I said "you can transcribe this report if you want to but my initials are not going on it." Bottom line --my co-worker got mad and said "Well you can call Dr so and so if you want to", like I was going to get my head chewed off. I said, "Give me the # and I will. I called and the doc said "Oh No, thank you so much, there is no lesion". My gray-area MT co-worker would have made a huge mistake and if the doc did not catch it before signing it, the patient would have been told his cancer had recurred. We are MT's not docs and we are not the ones that perform the surgery, examine the patient, read test results, etc. While we can tell you what the doc has messed up on 99% of the time, that 1% could have a devastating effect on the patient if we are wrong. JMHO.

Did you even read all the posts? OP said she figured out "near as possible" - what Dr meant. All other posts slamming her for th

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x

EXACTLY! Verbatim transcription is a fallacy. - NKC

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Verbatim only works if the dictator dictates perfectly and we all know that does not happen, EVER!

A seasoned MT has both excellent skills and excellent judgment. A seasoned MT knows what the doctor is trying to say even if he or she can't put a sentence together to save his (or the patient's) life.

And you absolutely cannot transcribe verbatim with a dictator who uses a conversational style. We are not court reporters who are required BY LAW to transcribe every "um" and "ya know." We are transcribing medically technical documents that become part of a medical record used as a reference by medical personnel. The reports need to be accurate, concise, and organized.

Not "ya know, the um patient, was taken to the uh OR and uh was ya know kinda prepped and draped..."

But MT also should not "guess" what dr means. No MT - I know is also a mind reader. nm

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x

Nobody said to "guess." If you are worth a dime as an MT, - NKC

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you know when to help the dictator and you know that when you and the dictator are unsure, that is when it should be blanked. It's that simple. If you can't make that distinction, then you aren't a very good MT.

OP says she figures out "as near as she can..." How is that any - different than guessing? She is not 100% sure. nm

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There are facilities out there that want what is - sm

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dictated exactly--be it right or wrong. I happen to have an account exactly like that. Unless the pt is a male and the doctor says female, we are not allowed to change a single word---and if they are listened to after transcription and a "the" or "a" is left out, we are called on it. Right or wrong there are totally verbatim accounts out there. (This is a major hospital that requires this)

Ah, but see you used judgment when you changed - NKC

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female to male. You actually used your powers of discernment and discerned that the dictator made a mistake. If you were "strictly verbatim," you would have typed exactly what was dictated, right or wrong!

That is why verbatim is a fallacy!

That may be what YOU do, but that is very dangerous. - Whose job description

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You state, "We are medical language specialists." Okay, that's true. But then you state, "It is our job to INTERPRET what they dictate and transcribe it." Says who? That's pretty dangerous business to be "interpreting" what any doctor may or may not mean. I don't know who handed down that job description to you, but at my company that attitude would never be acceptable. Blanks are much preferred to an MT's interpretation or better put, a guess, because you in fact do not KNOW.

IMO, physicians, NPs, PAs, or anyone else dictating should be held to the same high standards in dictating as the MTs are in their transcription for them, as truthfully that is part of their job too.

It would be dangerous to assume that you can "interpret" any sort of dictation that is confusing. Their receiving blanks back on their dictation (even repeatedly) is a message to them that they need to do a better job at being precisely clear on what should be transcribed. In the end, none of us are mind-readers.

Intended for "That's what we do." - sorry, misplaced. NM

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You figure it out "as near as you can" and send it through... - sm

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please let me know what hospital you type for, I don't want you doing my reports! What if your mechanic fixed your car and put on a part that kind of fit, but not exactly?

If, like you said, this account is verbatim, then - sm

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figuring it out as near as you can is not transcribing verbatim. If you can't understand the dictation you don't guess, period.

exactly - verbatim is verbatim

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Verbatim isn't selective. It's garbage in, garbage out. Otherwise, it's NOT verbatim.

I'd type every "you know" he says.

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