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So now leaving a mg off a med - is a 3.0 error?

Posted: Dec 27, 2014

That just seems weird. I get if it's supposed to be mcg and you put mg, something doctors often do in their dictation, but leaving off the mg, 3.0?

They are really digging deep into every document to find the means to which to cut our pay. I could never do QA/QC with this company, too nasty. We are perpetual victims, but they have become the freaking Spanish Inquisition. Honestly.

Really? It's not like hospitals use dictation to - dose medications. . .

[ In Reply To ..]
I was in the hospital for a few days over the summer. I sincerely doubt anyone looked at a dictated note to dose my meds.

All the nurses wrote the meds, dose and times on a white board in my room. They also wheeled around a computer and scanned my wrist band.

I have doctors that NEVER dictate a mg, mcg, etc.!!

Dictation, in my experience, has always been used for billing purposes.

Was it dictated? If not, - I can expect 3.0 off, too. sm

[ In Reply To ..]
When a dictator omits the "mg," it stays omitted. I will not assume what s/he means. If the omission was your error, 3.0 still seems harsh to me. Then again, by Nuance's standards, I put a patient life at risk (0.25 off) with a missing parenthesis.

I beg your pardon, it was not dictated, I got the - points off for ADDING the mg

[ In Reply To ..]
To be clear, I added mg and the mg value was not incorrect (i.e. the medication value would have been mg, not mcg or anything else). Apparently, adding the mg was the error.

So really, if the dictator does not dictate mg, say a whole slew of meds with just Lasix 20, metoprolol 50, etc., we are supposed to just leave it like that?

I always thought you were supposed to add the mg or mcg? Just a few years ago they seemed to make a big deal over that.

Well, I guess I can save myself a lot of time now (and hope none of those QA people find out I have been doing this on all my reports and ding me to kingdom come).

Thanks for making me check.

Ah. Got it. I stopped adding after getting dinged...sm - I can expect 3.0 off, too. sm

[ In Reply To ..]
...for adding the mg. This was a long time ago, pre-FIESA. Of course, N may change the rules again, just to keep us on our toes.

Yep you got that right, changing "rules" are their - forte....

[ In Reply To ..]
They need to keep ways to ding us and keep our pay in check. I get "changes" to account specs on a regular basis, even things like "start adding full year, i.e., 2014 instead of before where we were to only put 14 even if they dictated 2014. So what do you know? I forgot once and put 14 and got dinged with the comment "follow client specs." Totally makes NO different in the report and definitely NO difference in patient safety or care.....so ridiculous.

I DONT ADD ANYTHING they forget to say. - sm

[ In Reply To ..]
I get where the OP is coming from and back when I worked directly for the hospital it was okay to add things such as that when we knew for a fact thats what the doctor meant. But with these companies, if its something questionable whether I know the correct thing to do or not, I put a blank and leave it for QA to figure out; however, if you work for Nuance sounds like you are darned if you do or darned if you dont because you will be dinged then for leaving the blank even if it was left there to draw attention to a potential mistake.

If they are going to be that picky they should not count blanks against MTs, meaning only allowing you to send a certain percentage without it affecting your pay.

"Dinged if you do, dinged if you don't!" - ;D

[ In Reply To ..]
nm

So what if it is a list of meds and some have - mg after number and some do not?

[ In Reply To ..]
Surely there should be some conformity? And is this just for verbatim accounts or all?

It seems unprofessional to have lists of meds which have some mg and some just a number, not to mention just plain messy.

I have checked the guidelines and cannot find anything relating specifically to dosages.

consistency - and inconsistency

[ In Reply To ..]
To answer your question, yes, there was a time when I added the mg, mcg, mEq if the dictator omitted it for the sake of consistency, but not any more. I like the idea of consistency; it looks more professional to me. But now, after having been dinged to death for it, I transcribe as dictated. What really drives me nuts is getting dinged on Monday for editing for redundancy and then on Tuesday getting dinged for not editing redundancy. Can't win. As someone said previously, "Dinged if you do, and dinged if you don't."

dictate as transcribed - rock bottom

[ In Reply To ..]
Nuance guidelines specifically state that we will transcribe as dictated except
verb number will agree with subject
tense should be the same throughout the same (what I'm not sure)
errors in dictation
Anything in account specifics

So, if they state mg, type it, if they do not state it, leave it off.

If they dictate an error, leave it blank and flag it.

Not sure about adding headings, gotten dinged both ways, so unclear what to do.

I have added 'saturation' when the dictation is 02 100% on room air, because that is simply an unclear statement.

Nuance and the accounts don't want us being anything but a mindless pass through, like those translators or telephone operators for TDD, transcribe as dictated regardless.

We are not to 'edit' in the sense of making the dictator appear better or more clear. That is the dictator's job.

Ask for reversal. That is not a critical error. It is a major sm - TL

[ In Reply To ..]
and one of two reasons, either Downgrade Medication Dosage or it's a major omission, but it is certainly not a critical error.

Apparently if mg or mcg is added correctly - it should NOT be scored

[ In Reply To ..]
But you are not supposed to add them if not dictated. I would never add a mg or mcg without checking anyway, but now that saves me the trouble of having to.

Unfortunately for me I missed the deadline since I never got an email informing me of this - do they now not have to send the nastygram anymore, you are actually forced to subject yourself to checking continuously and thereby causing (in my case) high blood pressure? Ugh.

I got 3 points off for it which I cannot now reverse.

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