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

OH MY GOODNESS!! - MTconfused

Posted: Feb 01, 2011

I am so confused. I need to work like the rest of us and sometimes I pull my hair out with dictators that are beyond ridiculous and never told to speak any better, but this I think might have gone too far. I was looking at old reports for clarity on some medications, information, et cetera on one particular doctor, who is not a bad dictator at all, and repeatedly, I saw the initials of one transcriptionist who literally put garbage in all his reports. She literally put Doo-dah, patient ate fever, pussyboot, broke back mountain, black ass, just to name a few in these reports. Oh my god!! I have never seen such a thing, it was at least 7 reports so far on this one doctor. I am not a snitch either,but what do you do in this situation. What if this result in this company losing their account and the rest of the MTs looking for a job. Oh my goodness, help!!!!!

Is it snitching - to care about patient care

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Can you in good conscience not bring this to the attention of your superiors? If it were your mother's report, would you want an MT in your position to just ignore it.

The MT should be fired. Period.

That's right - ontop

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I completely agree!

I would mention it to someone. Those words should not - me

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even be in her expander. If I were in charge of transcription contracts I would cancel it ASAP. This would tell me they don't have quality MTs, nor do they have a QA staff. You don't have to mention initials if you can just list job numbers and ask someone to take a look.

Don't feel like a snitch and report the job numbers immediately. - ndmt

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What happens then is totally beyond your control, but if that was someone working for me, they would be fired. And shame on that MT for dragging down a profession that so many others are trying to build back up.

I'm dying of curiosity as to how the words "black ass" were used? - NKC

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Or any of the others for that matter. I wonder if this MT didn't do this on purpose for whatever reason. I mean, pussyboot? Who could type that word and not say "WHAT!" and rewind for another listen?

Would it rather be VR than expander though? - No message

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x

Hmmm. All I know is I don't have those terms in mine. - Stodgy

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x

unacceptable - sm

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That's awful! I'd report it ASAP. The strange thing is, why haven't the docs complained? They probably aren't even reading the reports they sign. We all make mistakes, but this MT needs to find a new career - tomorrow!

Good luck. I know you may feel like a snitch, but this makes the entire company look bad. You would be doing the right thing.

your violation of HIPAA? - ICManiac

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I haven't read the HIPAA rules is several years, so it is possible I don't remember it exactly right, and hopefully someone will add some clarity.

Is it a violation for you to have looked at the other reports in this manner? What is in your contract with the MTSO or physician about looking at prior reports? One part of almost all computer systems these days is a detailed daily accounting of what reports you access during the course of performing your duties. I've seen some contracts that say you can't look at prior reports that have patient names, some that say you can, and some don't address it all.

I'm just wondering if you were to say something if it could backfire on you, so I'm not trying to be hard to get along with; I'm just trying to ask a question.

I believe HIPAA says that we are allowed to access - NKC

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a patient's medical record in the course of doing our job. I take that to mean that we can use a patient's medical record as a source of reference.

That is absolutely correct. We do it all the time for reference. - Allowed access

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nmnmnm

Absolutely allowed access (sm) - Been there done that

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Every place I've worked for (from home) in the last 15 years allows access to patient records for reference and assistance in completing a report. It's usually password protected and in some cases leaves a "footprint" of who has accessed the record for documentation of that. It is not a HIPAA violation.

I'm not sure of the specifics - no1joe

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or what the exact rationale behind it is (and I'm waaaay too tired to look to verify), but I believe it's not a violation to look up prior reports for a patient you are working on. My company allows it too, and when you're dealing with poor dictators, it comes in handy. When you're dealing with really, really bad dictators or need to check a prior DOS, referral source, a discrepancy on the report you're working on, etc., it could be necessary in order to perform your job. If you think about it, if you were in office and had the patient's chart in front of you, the same reports would be there just in paper form, and you would have access to it. Now, and I'm not 100% sure on this one, but I think it's a no-no if you access a patient's file that you are not working on. There's no reason to do so to perform your job and, therefore, would be a violation.

Transcend's new platform will allow - viewing of previous reports

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Therefore, I cannot imagine that this would NOT be allowed under HIPAA. Say what you will about Transcend, but I know of at least one person who was fired for a HIPAA violation that involved letting a report go through without verifying the demographics--and of course, that was the one time where what the dictator punched in was wrong, and the dictation did not belong to that patient. I say that to point out that Transcend is very concerned about HIPAA compliance; and therefore, if looking at previous reports were a violation, the new software version that is being released this year would not permit that.

Besides, if they can get into a detailed accounting of the reports we access, surely they can block our access to things we are not supposed to see. If they allowed us access to things we weren't supposed to see, and then fired us for having done so, well, I'm not a lawyer, nor do I play one on TV, but I'd call that entrapment, or something.

Just had to take a refresher course and you are - sm

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able to look at previous dictations if it is in line with your job--difficult dictator or to verify something on the patient you are currently transcribing on--medications, history, etc. You cannot just look at any patient record because you are curious. No violation if it is in the course of your job.

That one sounds to me like a VR report that either fell - through the cracks, or wasnt edited well. nm

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,

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