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doctors who abbreviate drug dosages - JustMe

Posted: Jun 18, 2015

I have noticed a disturbing trend with the doctors I transcribe for. They will dictate medications in a dangerous way. For example Nexium 40 rather than Nexium 40 mg. They are seldom dictating mg, mcg, etc. I find this dangerous and wonder if it is laziness on their part or apathy or something else. Not to mention that it falls on the MT to "help them out" so to speak which takes time. I just find it frustrating. Thanks for listening.

Would not help out - on this

[ In Reply To ..]
I'm all for being helpful, but I would never put in mg or mcg if they do not dictate it. If they say Nexium 40, that's what they would get.

I would never add to a patient report like that - sm

[ In Reply To ..]
I've been transcribing a lot of years and in the good old days, I can't remember even one doctor who would truncate a patient's medications like this, but nowadays, I transcribe for quite a few who have started doing this.

I think it's mainly because the doctors are trying to rush through their documentation, so they're shortening things wherever they can. I also notice them dictating with a lot more short sentence fragments too. I think maybe all this "text speak" is evolving into a modern form of "medic speak."

But, I don't have access to the patient's record and I wasn't there during the exam, so if they dictate Nexium 40, that is exactly what I type. I will never ever add the mg, mcg, mEq for them. I'm just not willing to add something to a patient's report on my own like that and take that responsibility onto my shoulders.

It's just like the MT who got a critical error from QA because the dictated BMI did not match up to the patient's height and weight, and she got drug through the coals for not automatically calculating the BMI herself and typing in the correct number instead of what was dictated. BUT...how do they know that it was the BMI that the dictator got wrong? Maybe he mispoke on the height and/or weight and the BMI was in fact correct and it was actually one of the other values that was wrong. Without access to the patient's chart, the MT has no way to know for sure.

I don't like it either, but - GT

[ In Reply To ..]
at the last hospital I worked for, it was a requirement that the MT/Editor would add the unit of measure for medications when the doctor did not dictate it.

I think a hospital MT is different - sm

[ In Reply To ..]
Hospital MTs usually have access to a patient's entire medical record or at the very least have access to their past reports.

I am an IC, working at home, and I am just transcribing reports blind, without being able to see the patient's records or any past reports.

If I had the ability to look things up on a patient, I would have no problem with adding some of these things. But, since I am typing single reports in total isolation, without the benefit of past documentation, I am just not willing to take the leap of faith and add things that I don't really know. What if I'm wrong? It would then become my fault if a patient was injured or died and I'm just not willing to take that chance with another person's health or life.

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