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

Normal ROS & PEs - Morgan

Posted: Jan 26, 2013

When a dictator asked that you insert a normal ROS or PE, then dictates "for the respiratory put ..." I often get dictation that contradicts what remains in the normal template but the dictators do not instruct to delete the rest of that heading. Sometimes this is an easy fix, for example if you know they complain of SOB, then you delete that portion. Other times we can't possibly know how the "normal" differs for this particular patient. It's time consuming to keep flagging these for QA over and over because the doctors don't take the time to be clear. I wonder if any of you have any shortcuts to this like deleting the "normal" portion under that heading to leave only what they have added, or replacing it with "per HPI?"

Explanation for what you are hearing - Clinical Documentation Specialist

[ In Reply To ..]
When he tells you to replace respiratory with blah blah, that is not unclear . . . he means for you to replace all of it. You should not be trying to figure out how the rest of it should read.

Do not rewrite anything else. Just delete the rest. You risk less error that way and it IS what he said to do.

Absolutely do not change anything to "per HPI" as that could be meaningless, could introduce more error, and can interfere with coding and billing needs. Many physicians are being instructed to never use that phrase for those reasons. It is not helpful for you to put those words in their mouths.

I was an MT for years until I changed careers, so I understnd this from your perspective, but I am now in clinical documentation improvement, so I see this from another perspective, too. When he says to replace respiratory with whatever, do that.

What is it you do now? - Curious NM

[ In Reply To ..]
x

Clinical documentation improvemenr - Just google it

[ In Reply To ..]
You can also go to the ACDIS website for more information. That and AHIMA are the main certifying bodies for it.

It is something coders often advance into. You find mostly coders, RHIAs, and RNs in it.

How to handle it... - MT

[ In Reply To ..]
I've worked for years with physicians who use templates. When they say "add to," you simply add what is stated and do not delete anything in that particular section. When they say "change" or they just state, for example, "respiratory" and start dictating, then you delete the template part and put in what he dictates. You are not in a position to decide whether the rest of the template is edited based upon what is dictated in the rest of the report. It is the dictator's responsibility to make corrections as needed. You are also not required to flag the report if the template and the rest of the report do not match unless specifically required per facility, although I have never worked somewhere that required flagging for that type of discrepancy. The dictator can make changes before signing the document.

Thanks Everyone, but... - Morgan

[ In Reply To ..]
The problem is the dictators never use the simple words "add" "delete" or "change" they say "put", i.e. "put under cardiac blah blah blah".

Also I know most doctors do not read their reports, usually just a quick glance of the page and maybe the Assessment & Plan.

I'm just not comfortable with the sloppy dictation practices today as the dictators don't seem to be able to safely use templates. They request templates by the wrong name or want their personal template which does not exist. It just seems they are more interested in volume than accuracy of the report.

Funny, I was just going to reply that I'd consider "put" as "replace." - sm

[ In Reply To ..]
Luckily for me, I hear "add" a lot, so that's a no-brainer, but I also get ambiguous alternate words to "replace," in which case I do as others here have mainly suggested, just over-write what's there with the dictated statement, even if rather briefer than the normal. Just much safer overall and not worth worrying about to the point of flagging, in my opinion.

What I Do - see msg

[ In Reply To ..]
I delete, then just type what he says. If it is a discrepancy with another part of the report, on my accounts, we are allowed to flag it and send on to the client with a short note. I don't write a novel. I just put "in respiratory exam, shortness of breath" In HPI, no shortness of breath.

If you're not allowed to flag at all, I still would say you're safer deleting the "normal" part of the exam.

It can get tricky. sm - anon

[ In Reply To ..]
If your account specs include specific directions for those dictators who use normals for their ROS and PE, it can get tricky. You should refer to those first.

Similar Messages:

Mar 15, 2011

baseline normal or near normal thyroid function studies. Is "near normal" hyphenated, or no? Thank you. ...

May 26, 2010

s/l cell in dis thees with an MCV of 89. ...

Jul 15, 2012

? ...

Nov 30, 2012

PE on neurologist consult. Pt with spinal sarcoma. Doc is a pretty clear dictator. Not sure if "tesseril" is actually "tests for all" or what. How about "effort". Is this customary in a neuro consult? Thanks for any suggestions. ...

Apr 09, 2010

I am a fairly new MT at MQ. With all the checking ADT and getting different facilities/doctors I am very slow. What should my speed be at as a new MT??? ...

Dec 16, 2010

TIA ...

Jan 17, 2013

I know V4 is an ECG lead, but I have never heard it stated like this. Please advise! ...

Oct 17, 2009

what would S pep be referring to? ...

Sep 14, 2012

Does anyone else get scared when they start? I'm shaking inside. Is it just me or is it normal? ...

Nov 17, 2009

Mycamine 100 mg in 100 normal saline infused over 60 minutes daily. My question is about the 100 normal saline. I searched for this in quotes, and did not come up with anything. Is 100 a percent? Or do I just type it as I did above? ...

Jan 05, 2010

I'n new to working from home, only 3 months now, but have been a transcriptionist for 6 years. The company I work for has me on 5 different hospital accounts. They are all rehabilitation hospitals (acute) and do H&P, discharge summaries, daily notes, consultations, etc and I am constantly out of work. Some days I have no work at all. Pay is 0.0775 line except headers/footers. Is this normal? Each hospital is at least a 50 bed hospital. I f ...

Jan 16, 2010

From a neurology dictation. Thanks. ...

Jan 20, 2010

At my company (a smaller one) there are a lot of mistakes in the normal dictations that the doctors request. The way they are created in the first place is the transcriptionist types up the report and sends it to QA saying the doctor would like to use this in the future for his normal, but I don't think they get reviewed by QA. I think they just get created the way they are. So if it was a right eye, the word right is there all the way through it. If a word is misspe ...

May 14, 2010

d ...

Jun 26, 2011

I am thinking for right now I don't really care if I "fudge" on my shift a little here and there. First they offer OT, then no work. I almost think it might be better when we are under different management. HOWEVER, I still have not seen anything on the acquisition other than what we were originally told. How odd!! Makes you afraid to go with any of the smaller companies. Who knows who will be eaten up next. I will say I was an old YOG employee and when ...

Dec 09, 2010

xx ...

Jan 19, 2011

Doc wtih a heavy accent dictating: Heart: Regular in rhythm, normal S1 and S2, no gallop, no s/l "exosystolies". ...

Feb 11, 2011

.. ...

Feb 19, 2011

HEENT s/l gershin normal? ...

Mar 15, 2011

New Gastro doc. Sounds like he is saying: "Rectal tone is normal (s/l) 'oh-tuh-high'. There were no masses palpable." It sounds like he's saying it as one word. (No accent.) ...

Apr 07, 2011

to tell you that they will not pay you until the doctors/accounts pay them? Would you take the job even if you had been reassured that this is never the case? TIA ...

Sep 01, 2011

nm ...

Sep 05, 2011

I am preparing for the RMT exam. How much detail of the normal lab values do I need to know? Do I have to memorize all the normal values at the least? I find that impossible. Do I have to know what test will diagnose for which disease or particular study? For example, do I have to know that white blood cells are involved in the CBC test or that PSA stands for prostrate specific antigen and is a cancer marker? How much information about the drugs do I need to know? What kind of lab valu ...

Nov 30, 2012

We are inundated with sloppy dictators, perhaps the ones that can't use VR. We know how much they hate to dictate repetitive ROSs and PEs, thus they love using templates, or paragraphs from previous reports. Does anyone else note a lot of doctor errors in using these methods, i.e. racing through and not changing all the template details? I have found that NPs and female doctors are able to multitask and get this right, but the only males that can do this are the older ones who have a lot o ...

Mar 23, 2013

Just wondering. I always typed either per minute or per page. ...

Jan 03, 2014

Okay pulled in PE and major ARGH!!! I was told that tenses need to match. However, in this particular case whoever entered it was jumping back between past and present. Another time consuming thing I get to do. Interesting how that works. REALLY???????????????????????????? ...

Jan 20, 2014

And I got more of some of the normal accounts..And guess what? Line count almost doubled. So how is this fair to us that are stuck on thes accounts on a day in and day out basis? ...

Jan 17, 2015

in each report? My current accounts allow up to 3. I heard there are ZERO blank accounts. If I ever get transferred to one of those that will be the last straw for me...I'll leave because if I couldn't leave blanks (for those inevitable horrible ESLs) I'd ALWAYS have over 10% QC, and I refuse to work for 7 cpl. For those on zero blank accounts? That is not fair. Are you at least allowed higher than 10% pended? Do these accounts have clear ...

Oct 20, 2009

xx ...

Oct 25, 2009

xx ...