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Verbatim accounts -- What do you do when the doc goes on for three months with no break, sentences, - cardmt
Posted: Jun 23, 2013
I was corrected for not making one sentence into about two pages, like the doc dictated. Do many places do this?
It depends on how fed up - I am feeling...
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They can either have it correct or have it "verbatim," which to me is saying "you are so stupid we don't trust you to make a correct report."
Yet another thing that makes this job absolutely sickening. Honestly I just don't care what this garbage looks like any more and hope to put it all behind me soon.
I'm sorry you're not happy - cardmt
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I wasn't even really complaining.... I was just kind of surprised that they actually wanted it that way and put it back the way it was dictated. You're right, it does look idiotic but now I know for the future, I guess !
and the definition of verbatim is.... - sm
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garbage in/garbage out. What's not to understand? They want verbatim - give it to them.
My job is verbatim, BUT - sm
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We are required to use our "common sense", which actually is worse, because it leaves too much out there to be faulted for. In your case, we would have been required to correct his sentence.
I have typed where the doctor says "He has got 2 of them" and I type it like that, but of course, it's supposed to be "He has 2 of them". These policies of transcription have really gone mad, in my opinion. QA people chop reports like they have a doctorate in English, which is a waste of EVERYONE'S time. I can bet you that even a doctor doesn't know all of the corrections that QA makes to report. Even doctor's don't know the correct use of commas or semicolons. It's just a way to belittle us and make us feel of less worth. Very aggravating. Unless an MT types something that causes the report to not mean what it is supposed to say, then it should ride.
Seriously? My editing always keeps the patient and the reader - in mind. Documents are clear and easily readable
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when I send them. Thousands and thousands of patients across the country are being injured and are even dying because of medical error, but not because I followed what I imagined to be rules instead of doing my job.
BTW, I work for Nuance, with its horrible, keep-us-poor QA standards, and I've never gotten called on this. I make corrections as needed so that no one has to go back and re-read to understand, or worse, continue on mislead and clueless. BUT, if I were, I'd be well positioned on the high ground to argue my point.
Verbatim - Addison
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One time, I changed a horrible run-on sentience into 2 sentences by doing nothing other than deleting "and" and then adding a period. The report had to go to QA to fill in a blank, and then QA not only changed it back to the run-on sentence, but made a subject-verb agreement error in the process.
verbatim - xx
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Pretty much depends on my mood that day. :) I was told many, many years ago by my instructor, that our job is to make the doctor sound smart. I'll never forget that.
I have all verbatim-verbatim accounts and only just now learned that we have to change what the dictator says and change it to an "approved heading." I was once told this only pertained to non-verbatim accounts, but was just corrected. I was told that ALL OF THE CHECKED headings in the headings pane must be included in the document. If the doctor says procedure, you must put in an approved heading into the standard changing what he says if in the approved headings list it says ...
the doctor is dead wrong about his anatomy? The patient has a problem with his foot and leg, but he dictates ulna. I wouldn't give it a second thought to leaving it blank, but I already got notice about documents with blanks (usually 1-2 blanks if any, and anymore than 3, to QA). Hmm... go with what is right or what is the least path of resistance (i.e. least likely punishment)
BTW - The document I sent yesterday with 4 blanks to QA, they couldn't fill them in either. Shesh, the ...
The reason I ask is because this morning I'm doing an acute care progress note where the dictator says "The patient has end-stage chronic obstructive pulmonary disease and she is still sounding pretty crappy and congested." I absolutely refuse to use the word "crappy" in a medical document if it is not within the context of a direct quote from the patient, i.e. "I feel pretty crappy..." So I decided to omit crappy and just say "she is still sounding pretty congested." QA w ...
I was just wondering if anybody out there knows how to switch back and forth between capitalizing the first letter of sentences and not capitalizing. This is a problem when I go to type H. pylori or C. difficile, because it keeps capitalizing the "Pylori" and "Difficile". Of course, I asked Support, but they said there was no way to change it. I just wondered how you guys handle this. Appreciate any help!! ...
Continue Sinemet tablet 25 mg to 100 mg orally 360 one tab q.i.d. 90 refills 3.
she actually says "25 mg dash 100 mg" but I put the "to" instead of "-"
I am not sure how to punctuate that sentence or break it up if needed?
thank you!! ...
I had found an answer somewhere about this problem, but naturally can't find it now:
The patient will be followed in 6 months' time. OR
The patient will be followed in 6-months' time.
Thanks for the help. ...
how is the platform. I know people have negative comments about them but are there any positive ones. I would only try it PT and IC. Not sure that would work out or not. ...
is that correct? If so, are CB and DF still involved? I love Bayscribe, and I was thinking about biting the bullet and applying to Nuance for some PT work, but I kind of butted heads with the 2 ladies and so I don't want to waste my time. Thanks for your input. ...
This is EXACTLY how it was dictated:
I cleansed the skin with alcohol from her prior visit (LONG PAUSE) I do remember patient having a very low pain tolerance.
That's pretty unsanitary to use alcohol from the prior visit, don't ya think? LOL ...
This is almost/sort of a poll. I need to know what verbatim means to you in VR.
Do you change any wording? My understanding of verbatim is word-for-word (Merriam-Webster dictionary) unless a sentence does not have proper structure; if the doctor rambles on and puts the word 'and' between words where there should be a period, etc. (Not included in this is changing mg to mcg in a wrong dosage, changing the medication itself if wrong, or other major medical erros&nbs ...
Just worked on an ESL report (with unfortunately for me very, very, very little English). This is a VERBATIM account. Sent it to QA and it was "transformed" into English with little regard for that pesky word VERBATIM. Does verbatim mean different things to different people? ...
If not specified, is it better when taking an employment test to type verbatim or to follow transcription rules? Not asking for a specific test or company, I have just noticed that often times no instructions are given, and I don't know whether they are looking for following transcription/AHDI rules or just running the test next to a template in the system. ...
lisinopril/HCTZ 20/125. I'm sure she meant 12.5 but she clearly says 125. I don't want to leave a blank as I get penalized. I'm thinking to just do as I know and put 12.5.... ...
Hi everyone I may be getting a job which is a verbatim account. I have not done that much verbatim work and I was wondering, are there any tips I need to know about doing such an account ? I realize that verbatim means exactly the same words but if any of you have any tips typing verbatim I would really appreciate it. Thank you in advance and I hope everyone has a great week. ...
significant for hypOtension and a few diagnoses down from that hypeRtension. I would leave it a blank if it did not cost me money but not sure she meant the hypOtension. She repeats herself alot but she clearly says hypOtension. It's a guessing game! ...
AHDI has stated "that obvious headings that are not dictated may be inserted but this is not required." Does anyone know if this applicable in verbatim accounts? Has AHDI issued any new or different rules in regards to verbatim account? ...
I was just curious how often you get up to stretch your muscles and move around, etc. I am trying to every hour or so take a 5 minute break or my muscles in my upper back and neck start to ache.
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Is it me or what - I was always told to follow account spec and make sure I didn't use the forbidden JCAHO abbreviations.
Lately if I look at an old report to get a slurred/muffled word that I can't make heads or tails out of, I've noticed that others on my same account don't follow the specs at all! They do everything verbatim. It totally upsets me. I noticed it a while back and put it down to a new employee not yet knowing all the specs, but it wasn't as ba ...
clearly dictates a sentence that makes absolutely no sense. Just sort of an open-ended sentence, not even a fragment? I'm trying so hard to keep the blanks down, which my % is really okay, but I'm finding more and more that these docs are just not making any sense and the mistakes are getting ridiculous!!! Maybe they are texting when they are dictating........Anyhow, do you just type what they say and send it off or do you mark it for QA? ...
I started with a company recently, (within the last 2 weeks), that was all straight typing (yea!), but verbatim and I do mean verbatim. Most of the reports had the headers built in, and I did them in the order dictated. However, there were certain things in the operative reports, where they wanted things put in a certain place. I got that part, after receiving emails from the QA team and put the headers, where I believed they wanted them to be. The headers that were ...
Even on a verbatim account, would anyone ever transcribe '85 instead of 1985 standing alone within a sentence? I personally think this is just crazy, especially when the account specifics show dates as mm/dd/yyyy. But, hey, I'm just an MT. But in all these years, I have never transcribed a year this way. Comments? Thanks. ...
I get so tired of these people slurring everything together, speaking so fast because it's what they always say. Then we're told by QA, they the same thing over again so you should know what it is. If I could understand it, I wouldnt leave a blank!!! We're told not to guess. Especially lab values or other numbers or values. No wonder we leave blanks, when we can't tell if it's 180 or 190 because you're speed slurr ...