A community of 30,000 US Transcriptionist serving Medical Transcription Industry
kind of intesting with Medquist - just want to work
Posted: May 23, 2011
just got off the phone with a person at the Q who should know questions about the acounts, right, and so I ask her if a heading should be social history (I'm old school) or just social. I can't find the answer in BOS or client profile. She says well, probably put what they dictate. She says, I don't really know. In other words, she did not give me a definite answer. I say, what if that gets corrected and we are now at 99%, that gets me fired. She says, yea, I guess you're right. So, I look at it like this. I am s-----d one way or the other.
I thought we were to use standard headings - for the Q already in DQS
[ In Reply To ..]So if the dictator says HPI, you type "hhpi" which brings up the header HISTORY OF PRESENT ILLNESS.
I would put "SOCIAL HISTORY" if the dictator says social because that is not in our "PRESET" headings from the Q.
Also, if I understand this new grading system, anything that does not affect patient care would not be critical and would not fail you on an audit.
I put it like they say it. - dumbdumb
[ In Reply To ..]If the heading is "assessment/plan" and the doctor says "assessment AND plan" I change it, etc. Could be one of the reasons I don't make money any more.
I have one doctor who dictates "recommendations and plan" - ASR puts
[ In Reply To ..]"Plan and recommendations" EVERY time. Drives me crazy, but I change it just in case.
According to MQ First Time Right training - CyberlandMT
[ In Reply To ..]If a client has subscribed to the program, the approved headings will be in the pop-up header list and you can just select them. However, it also indicated to transcribe exactly what the doctor dictates and if the client wants it to be a preferred heading, it will get changed on the back-end. In your case, Social, would be all you need to type. As usual, ambiguity of directions. I just think the whole thing is malarky, since only a handful of the clients even use that thing. I'm like you (old school). I was taught years ago in training that when a doctor dictates past history, to use the entire commonly accepted term, past medical history. That's what I do to this day. If a doctor dictates socially... I change it to Social History heading and then begin the text of whatever he describes underneath. I've not ever been dinged for doing it that way...but who knows what is to come to pass with this new auditing procedure. Guess we'll all see soon enough.
that is only if heading feature is on screen on left - otherwise use preset headings
[ In Reply To ..]It only changes on back-end formatting if this account uses the heading list feature which would appear on your screen.
Otherwise, you would have to use Ctrl H to get heading list and use from there.
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