So, do I go with verbatim (verbatim account) or leave a blank if

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 ...

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 ...

The dictator clearly dictated a word with an apostrophy following it. The word actually has an accent mark following the last letter, but he specifically dictated an apostrophy. I got it marked as an error. I don't get it -- it was a verbatim account -- I did what he said - and now it's error. Frustrated!!!! ...

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? ...

would you just put pip-tazobactam?? I'm also thinking she made a mistake saying pip which I know is piperacillin. Thanks so much! ...

How are you liking it so far? ...

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 ...

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. ...

Plus more corrections to ASR. Oh goody. ...

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 ...

If whatever the doctor said is a little wonky, doesn't make sense or is a bad sentence, you can and will get dinged for typing what the doctor says. Told to leave a blank so you won't get dinged. ...

I started a second job for extra money and so I'm on 100% QA. I keep getting feedback for what I consider to be the most inane reasons. I am old school. When a dictator starts as sentence "patient is here for..." I type "The patient is here for ...." So QA has pinged me several times for not typing "verbatim." So I've tried to be very conscious and listen very closely. Now I've gotten feedback where I clearly thought I heard patient, typed ...

I was corrected for not making one sentence into about two pages, like the doc dictated. Do many places do this? ...

and doc is saying drug to be given q.Tuesday . I want to put each or every Tuesday. Would it be q.Tuesday??? I am second guessing everything I do anymore!! TAI ...

Thanks for the info! ...

Is one or the other just a given? Please help! ...

Particularly I never know what to do about headings. If they never dictate headings, it is no problem - I do not put them in. But if they dictate no headings, until all of a sudden towards the end of the report, they dictate one random heading, then it makes the rest of the report look stupid without headings. Would you put in headings for continuity in the rest of the report, or leave it looking stupid with, eg, one single heading i ...

So, do I go with verbatim (verbatim account) or leave a blank if - Just shoot me.

Don't Work There Anymore, But... - MT

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