Excellent article about the deterioration of notes for patient care

Excerpt: Free-text narrative will often be superior to point-and-click boilerplate in accurately capturing a patient’s history and making assessments, and notes should be designed to include discussion of uncertainties.” (italics DMCB). Link: http://www.kevinmd.com/blog/2010/05/ehr-notes-cut-paste-documentation-problem.html ...

Are there any other Tier III critical care MT/editors getting only clinic notes? ...

Which generally pays more? Is there any speciality that generally has a higher cpl rate? ...

Moderate, please don't move this to offshore board. It needs to be seen by more people. Exerpt: "The new law imposes limits on outsourcing by American insurance companies and medical service providers. In addition, several categories of data are prohibited from flowing offshore. As a result, many Indian outsourcing firms have begun setting up shop in the United States. America’s outsourcers are now outsourcing back to America." Link to article: http://medicaltourismmag.com/news_ar ...

The job posting on the job seeker's board sounds fishy to me. It says "no phone calls, please" but there's no phone number or company name even listed! I bet it's one of those scammers that want us to give THEM money, and then they'll let us work for them. ...

The whole purpose of this new compensation plan is to focus on quality patient care, supposedly. After 20+ years in this field, including multiple years within an office and seeing how these notes are used, I think I know a thing or two about patient care and how important the quality of the medical record is. Here are some things I know: Doing accounts consistently help you learn what doctors say from note to note. Likewise, it also means you're more likely to hear a mistake w ...

or a patient dying because of mistakes made in dictation/transcription, then why in the world is it acceptable for any dictator, be it MD, PA, NP, etc. to get on the phone to dictate half asleep, eating, or even probably drunk and get so confused themselves that there is no way you can understand what they are trying to say. When this happens REPEATEDLY, this person is called a "difficult dictator." However, if you make a mistake on their transcript or send it to QA, you are the ...

I spend more time trying to figure out what and whether or not I will be dinged for missing or "adding" 'the', 'a', etc. Getting dinged now for leaving output just as it was dictated. Got dinged for missing 'of' even though there was a note that it was dictated really fast. Got dinged for putting the beginning 2 words of one sentence at the end of the preceding sentence, and I remember that report. I could not figure out what the doctor was trying to say! Got d ...

How can I be? I'm too focused on what I'll get dinged for. Every other day there are updates to account specifics. How on earth can one remember every little thing for every single account (I do 5)? What will the auditor think of this or that? Should I actually type verbatim even if it makes NO sense? Should I change what voice wreck typed, i.e., "On physical examination, the patient..." The doctor actually said, "On physical, the patient..." So, this goes ou ...

I don't know about the rest of you but I have very few male doctors who are careful enough to adequately edit normal templates to meet the patient's particular criteria. It's gets pretty time consuming to do it myself, especially when we are not qualified to do this in every instance. Female doctors almost always attend to these details. NPs, PAs do a much better job than the male docs, but few male docs either care, feel it is their job, or take responsibility for this editing. ...

"The patient was advised to follow up with Primary Care." I have been capitalizing Primary Care....Is this correct? Need second opinion. Thanks! ...

"CAN'T-duit" for patient care and safety is more like it. The only way we "CAN-duit" is to be able to take the time to produce an accurate and timely documentation of a patient's story and have a compensation plan that is attainable. Instead we are pressured to produce more for less. Sorry guys.... not buying it. "Happy" MT Week??? Nope..... not EVEN. ...

When I SEE ads that pay 7 cents a line for IC, I want to put my HANDS over my AUDITORY canals and SCREAM BLOODY HIGHWAY ROBBERY. Take your list of requirements and stuff 'em. ...

I have thought about it, did some financial figuring for paying my bills, and researched different schools in my area that offer practcal nursing classes WITH the option to advance to R.N. once working and.... I AM QUITTING within the next 6-7 months. I HATE HATE HATE NUANCE and everything it stands for, and I am tired of being kicked around and stolen from. There have been SO many MLS quit from just my team, and I can promise you I am going to be the next one to go AS SOON AS HUMANLY POS ...

I took a test for an MTSO last week that required extensive knowledge of prefixes, roots, and suffixes. I found an online resource that resulted in my getting 100% on all 4 sections of the test. I have to admit that I knew probably 75% of them, but this resource helped me pass all of the tests. http://www.globalrph.com/medterm7.htm However, I haven't heard anything from the company other than "Congratulations! You passed all 4 tests 100%!" No actual transcrib ...

An excellent spinal anesthetic was induced and mantained without complication or (s/l emit). Also under the heading ANESTHESIA doctor dictates "Final" what does this mean? Thanks for help! ...

http://mtanywhere.blogspot.com/2012/05/transcriptionists-file-class-action.html ...

...bills. Most Saint hospitals and others actually operate as non-profits, and for what they are screwing us over in taxes unpaid, they can afford to help out folks with their bills and still give their CEOs generous stock options and obscene salaries! But, you have to ask for this after your visit, treatment, x-ray, or ER visit. ASK for help if you need it. It is not our fault that suits are in charge of medical care in this country. ...

We will have the patient seen by anesthesia preop to make sure the pacemaker is properly cared for during the surgical procedure, which requires general anesthesia, and the use of the s/l **bovig** during the surgery. Thanks!! ...

I just got another email from my QA super saying that I should have left a QA note for a report, however I did. This is the third time this has happened to me. I have called support and they say there is nothing wrong, but I only work 3 hours a day (other full time job during the day) so I remember the reports that I type. Is this happening to anyone else? I've am already on probation and this isn't going to look good obviously, but I don't want to sound like I am making ...

When everything after heading is numbers (such as IV FLUIDS 1500 ml, EBL 2000 ml, etc.), do you spell out fifteen hundred milliliters and two thousand milliliters? That is how I interpret the rule of not starting a sentence with numerals, but it really does cloudy the waters and make the op note less easy to read. ...

If you insert a QA marker, how do you close the QA note box at the bottom? Ctrl+C doesn't work. I have to manually click in the report to get it to close. Is there a shortcut? ...

Have you performed your upgrade yet, did you have any problems with it, and are we required to do it? ...

I used to specialize in op notes but for the past 3 years I have not found a company where I could solely specialize in op notes so I have kinda gotten rusty. What I have noticed in the past 3 years is the few op notes that have come my way are by the worst ESL dictators. Is this a trend in op notes now? Does it seem that they are done mostly by ESLs? I was just curious as to other MTs recent experience with op notes, especially those who work is mostly op n ...

especially if you're on a southwestern account and doing editing for the first time. I started with MQ last month and feel very discouraged, mainly for all the minor negative feedback I'm getting. I'd like to know how the other new employees are doing so I can get a sense of where I stand. I keep thinking any day now I'll get a notice I'm fired. Email me directly and dish it out. ...

I had op notes added to my q last week. My line count has went up quite a bit due to the doctors using templates for a lot of op notes and the fact that they say the same things usually. Anyone else end up with more lines doing op notes? ...

Did anyone who applied for the Surgical Notes position get a reply? ...

I have a chance to get in with an MT company that also offers their ICs a chance at live note taking. It doesn't pay too good, though, less than what the standard reports pay per audio minute. I have never done this. Can someone explain to me how it works? I have heard that "live notes are typed in one pass." What does this mean? ...

Excellent article about the deterioration of notes for patient care - Val

Forgot to mention - Dictating while talking w/ pt.

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