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I have a question regarding QA. Let's say you have a dictator who 9 times out of 10 dictates t - SM...

Posted: Sep 15, 2014

exactly the same on every report and you have put his ROS and PE in your abbreviation expander, but sometimes he will dictate something out of order. For example, the dictator still says the same exact things he always says, but sometimes instead of saying "EXTREMTIES: No clubbing, cyanosis or edema." He says, "EXTREMITIES: No edema, clubbing or cyanosis." Do you go back and change it or do you leave it since he is saying the same thing? And if you don't change it to the exact order he dictates it, is it considered an error?

All of my accounts are verbatim, so yes, I do go back and change it. nm - sadie

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nm

Well, I work for a small hospital as their transcription supervisor and - SM...

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I am in the process of trying to come up with guidelines for the department. I've been here about 10 months. My first order of business was to set fair production guidelines and insure that everyone was meeting at least the minimum. This was met with A LOT of resistance. I have three MTs who have been here at this hospital and ONLY this hospital for their entire careers. The idea of a minimum production requirement didn't sit well with them as they were used to transcribing 600 or sometimes less lines a day without any repercussions!

Having jumped that hurdle which took several months, I am now ready to tackle QA. One problem is there is no uniformity whatsoever in report formatting. One of the ladies has the newest edition of the AHDI Book of Style on her desk, but as far as I can tell she is the only one who tries to adhere to that standard and she only loosely adheres to it. The others just do their own thing. I have decided I need to sit down and actually write some guidelines for my department. I decided to start with the whole verbatim issue as I personally do not feel verbatim transcription is appropriate in all situations (as in my example posted above). I believe that most physicians expect transcription to clean up their grammar and arrange their thoughts coherently. I refuse to believe that MTs, with all the education and knowledge they are expected to have, should be relegated to become typing zombies, typing only what they hear and not exercising their brain.

I would like to know what the consensus is on the issue of verbatim. I know that most places and accounts require verbatim and I know you do what your told. What I want to know is what most MTs THINK about verbatim. Do you agree with it or not? What is your opinion (not what the AHDI says or what the MTSOs say)?

I've been in this industry for a very long time and I do not believe the AHDI to be the final authority in all things transcription. So while I am familiar with their book of style, I do not agree with a lot of their "rules." So when I write my guidelines, I am going to seek out the opinions of MTs who were in this business before and during the rise of the book of style.

As a small MTSO owner... - Toni

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...I do fix up their grammar, punctuation, etc. I don't do hospital transcription, only clinic. From my standpoint, I know most of my doctors and I know that they do appreciate our efforts to do so. In my 20 years of transcribing, I've only had one doctor who disputed a comma that I left out because I thought it was inappropriate to use it where he had it. Go figure.

My feeling with - "verbatim"

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and I put it in quotes because there are plenty of times when it is not appropriate, is that we started getting more and more of this when the quality of MTs started to decline, either due to matchbook schools or Indians. You are wise to require reasonable American English grammar standards in your department.

good for you - me

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One of my issues is being told to leave a blank when the dictator clearly states milligram when dictating a medicine that comes microgram (and vice versa) and not being allowed to transcribe the correct term. Some medicines may come either way, but there are some obvious exceptions. Dictating a medication that I KNOW absolutely is incorrect but the word they used was "close" to the correct word, again having to leave a blank instead of putting in the right word. I'm not using these examples as doubt of what was said or gray area either/or words. There are things that you know 100% in every fiber of your being and to be told to leave a blank is nuts. We all have an education, we all likely have things in personal life that make us "experts" on certain things. It would be nice to be trusted to use it.

Verbatim transcription - hjr

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I am a transcription supervisor for a large hospital group. I have been a transcriptionist for over 30 years. All of our work is outsourced overseas. I hate, hate, hate verbatim transcription.

If you are dealing with inhouse transcriptionists who have been there for a long time, I would expect that they would automatically clean up a ESL dictator's report. Whenever I get something back from the service by a ESL dictator, I must clean up the report (grammar, syntax, comprehension of what is being said, etc., in adition to the blanks they leave. It is my contention that if a transcriptionist does not know how to correct a report (grammar, syntax, etc) they should not be transcribing. That is what 30 years of experience should teach you, how to create a clean, concise report,not to type every word a provider dictates exactly the way he dictates.

Verbatim is usually just an - excuse for incompetence

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Verbatim started getting popular when offshoring took off, and, to me, is an MTSO's response to incompetence. You hardly ever saw it prior to 1998 or so, even with Medquist and whatever Nuance used to be, and when you did, it was the mark of somebody with very poor skills.

The BOS supported judicious editing and good schools taught it. It was the reason students from those schools got jobs and others did not.

Verbatim transcription produces a poor product. It is now one of the main reasons that physicians and facilities tolerate SR and point and click mess ... they do not see much difference between that and the verbatim garbage they get from MTSOs.

We are told verbatim but also "use your best judgment." - Can you imagine...

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It's not just ESLs we are awesome at making look good, but we have also all had those dictators that screw up numbers in a list, or say "paragraph" after every sentence, or the ones who think they are editors and love to pepper in colons or semicolons EVERYWHERE.

My experience with verbatim is that I once had - to go to court and testify

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about a specific case. It was a long time ago as we were still using standard cassettes. The judge listened to the dictation, read my transcription, and inquired if it was usual and customary to transcribe what the physician meant to say or transcribed verbatim what he actually said. It was our custom to transcribe verbatim and I so testified. Part of the problem with this case was determining why transcription did not change it to what he "meant to say." Since that incident I have always transcribed verbatim.

I do too, because clients sometimes "audit" reports ... - shadow

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because physicians make strange claims, like, "that's not what I said" or "they're changing what I'm dictating."

I once got "called on" leaving out, iirc, a few redundant "subsequently"'s in a report from a doctor who said the word at the beginning of every sentence.

My rule is -- if it's hard to explain why you do something (other than laziness), just don't. althoguh I certainly asked this same question when I was new and got crickets, and didn't change things for a while before I realized how unprofessional any excuse sounded.

Verbatim sucks even if it's "simpler" or "less work" it's very stressful to be typing bad English, particularly when you're also dealing with an ESL or even an English speaker whose English isn't that good -- Subject/verb agreement, verb tenses, and -- my most hated -- using peculiar prepositions.

Use of a standardized format actually makes the report easier to read and comprehend. I worked in-house with someone with "cre8ve formating" skilz ... looked unprofessional and busy ... our supervisor couldn't bring herself to be "the bad guy" and make her stop. Her reports looked juvenile.

If you're using speech recognition or will be using speech recognition, - gonesoon

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then you HAVE to do it verbatim and there has to be a standardized format, or the speech program won't "learn," and you end up with a bigger mess, which cuts down on productivity. Sad, but true, that is the way it is. We had that problem at the hospital I worked at.

Thank you all for your input. It is very helpful and very much appreciated! - NM...

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