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Helpful hints? - Trying to adjust to change

Posted: Mar 12, 2010

I got an email today with a bunch of FYI... do it this way, type it that way. I suppose it will be helpful at some point, but I just got feedback... back and for the first time ever I was corrected to type H and P instead of H&P. How do you type it, does anyone know how it is supposed to be? I think H and P looks stupid.

Also, doc dictated vital signs: see nursing notes and then went back later and changed it to unremarkable. The QA changed it back to see nursing notes because he/she didn't listen to the whole report, I am assuming. should I Do anything about it?

helpful hints - mushroom

[ In Reply To ..]
Someone else correct me if I'm wrong, but I believe we're not supposed to use the ampersand in any reports as it messes up the report when it loads or something like that. Can't do H&H, I type out hemoglobin and hemocrit or I guess you could do H and H, but like you said looks funky -- type out history and physical - get some extra lines! JMO

Be careful about expanding anything! Depends on your QC. - Mine gave me a critical error for that.

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I have a QC with an itchy gun finger and I get dinged for the darndest things. One of which is expanding H and H or H and P. I got 2 critical errors on one report for doing that. And it is a non-verbatim client.

I would say transcribe exactly how it is dictated even if it looks funky. Your funky is the client's treasure.

Client Profiles - MT

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Client Profiles are pretty specific on where to expand and where not to. You usually expand in the diagnosis type headings (asssessment, impression and the like), but not elsewhere unless specified. You probably got a serious ding because you didn't follow the Profile. They're big on following the profile. If nothing was in the profile about that, then that was an unfair critical error.

Excuse me, but it WAS an unfair criticar error. You are not the - only one who reads client profiles.

[ In Reply To ..]
My CCM made her re-do my audit. It was RIDDLED with errors. My CCM did tell me that other MTs have called her to have their audits re-done.

My QC is a CLOWN.

I don't know why my CCM will not do something about it if she is aware of it.

So just BE CAREFUL about EXPANDING even if there is nothing in the CP or otherwise to keep you from doing so.

I think they are still learning it themselves! - mrs.krabs

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And all of it amounts to a hill of beans. There is no way they can keep all the account profiles straight in their heads. I think sometimes they mark you because you didn't do it their way; it's all about style.

still learning it themselves... - vrinie

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''a hill of beans'' is exactly correct. Petty nitpicking. And if they are ''still learning'', then they should be cautious before making ridiculous so-called corrections.

& are now forbidden - nm - shipwrecked

[ In Reply To ..]
nm

Second post is right about the H and H. - Yes, definitely notify CTL. They need to know. NM

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If you do not notify CTL, it will come back to you later.

1) Ampersands are forbidden. 2) If a report is - sm

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going to QA and there's a change like that, I usually put a quick QA note to avoid that happening.

Medquist Guidelines - mt

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The ampersand being prohibited is on THE FIRST PAGE OF THE MEDQUIST GUIDELINES!!!! They have been out for over a year. And you are surprised.

IMO - if you do not do your job and pay attention to the documented guidelines, you lose the right to complain. Just because a QA person has not caught you in the past does not mean that this is something new.

I think MT gets "AND", but what about inserting - Oh brother!

[ In Reply To ..]
something in the report later (dictator's orders) and ends up getting into trouble because of it? You forget to answer that part of the question.

I am not the one who wrote the post, but I have been there and know how this MT feels which has been happened to me quite a few times years and years ago. I have been an MT for 25 years. There is a lot to remember ESPECIALLY when this company keeps changing their mind on things over the years. My statements are DARN IF YOU DO AND DARN IF YOU DO NOT! That is how it always has been with this company.

By the way, there was an account I have done for years who specifically wanted "the sign" instead of "AND" in their reports, but now the account has gone to EPIC anyway so who gives a crap.

I think the poor MT GOT IT! And by the time she gets it and in a few months it will probably change again. Hahaha.

To Trying to Adjust to change, regarding QA - changing things...sm

[ In Reply To ..]
Just a couple of weeks ago, got an email from QTL (or whatever they are called now) stating that QA should be very careful when filling in a blank that may sound "perfectly clear" to them, and may wonder why the MT/ME left the blank in the first place, especially regarding lab values
for instance hemoglobin 235 (just an example) as this would be a totally incorrect lab value for this. Also addressed was changing something or adding something without looking through the whole report to make sure that the dictator did not add or change it later on.

Hope this helps.

got an email recently addressing this exact issue..sm - Mtsella

[ In Reply To ..]
From CCM, email stating the following: QA team and MMEs, please be very careful, even though a word is clearly dictated does not mean that it is the right word in the given situation. Be mindful of what section of the body you are transcribing about before automatically putting a word in just because it is said clearly. This also holds true for lab tests.

Sometimes the MTs leave a QA marker even though the dictation is clear because the usage of that value or word in that particular sentence is questionable. One rule of thumb should be, if it is so clear that it makes you wonder why the MT did not get it, then your next question should be, maybe it is because it is not the correct word for this particular instance.

MTs, better than we get credit for - adios

[ In Reply To ..]
Glad to hear somebody gets us. I have left QA markders because something does not make sense, but if that is all that is wrong, I have started typing it and leaving a QA note to the client, bringing it to their attention, so they can figure it out.

In the past I have left QA markers only to have the blank filled in with what was clear, but made no sense. Made me realize when the report goes through QA they don't all spend quite so much time as we do worrying about the integrity of the report, but just filling in blanks. I don't really blame them. They are under more pressure than is healthy, same as we are.

I do think it's a little harsh to bash the poster about not being familiar with the guideliness. They change back and forth so often, who can keep track of it all?

And I say this, having no problems on my audits, etc. Just so dang much to remember these days, my head is spinning.

Get credit - sick and tired

[ In Reply To ..]
Doesn't help my old fried brain to have multiple accounts to try and remember. I get so tired of constantly looking up client profile. I have made crib notes for the important stuff, like how do they want dates and the physical exam to try and save some time.

DocQscribe guidelines 2.1 - mmeeeeeeee

[ In Reply To ..]
We were sent the DocQscribe guidelines 2.1 awhile ago. It gives a lists of characters not to use, and & is one of them. However, that particular character just applies to the retrofitted clients. If it isn't retrofitted yet, then & is supposed to still work. The same thing applies to changing cc to mL, I've been told. Change cc to mL if not retrofitted yet and leave at cc if retrofitted. I don't know why this is so, doesn't make sense, but it is what it is.

cc and mL - anon

[ In Reply To ..]
I have been told so many conflicting things about cc and mL. Have been marked by QA both ways. Figured if it said use AAMT guidelines and Do Not Use List I should change cc to mL, but apparently some QA thought if not listed specifically in Client Profile should stay cc. I can't win.

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