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Past or present tense voice - TenseMT
Posted: May 07, 2010
Okay, I have been very confused about this lately. When a doctor is reviewing medical reports from other providers and is documenting it within his report, should it be done in present tense or past tense??? I think that it should be done all in the past tense, but I have had arguments for both. Basically, I just want the right answer.
For example, "The patient was seen on 06/10/09 and stated that he had right leg pain. The report indicated that the patient had an antalgic gait." (my preference)
OR
The patient is seen on 06/10/09 and states that he had right leg pain. The report indicates that the patient had an antalgic gait
Aaahhhhh...My doctor keeps switching from one tense to the next and I am just trying to keep some form of consistency,although it makes more sense to note the above in past tense since it did actually occur in the past. What do you think????
I tend to do it as dictated - sm
[ In Reply To ..]For me... it is easier just to use whatever tense he is dictating it as, unless you are specifically told to 'make it match' in which case past tense definately sounds better
Past Tense - For Clarity
[ In Reply To ..]Change all the "old" findings to past tense. They could be mistaken for current findings otherwise.
IMHO - Bad Rabbit
[ In Reply To ..]As far is the first portion goes, I would have to be certain of when the patient made the statement. The patients states he had right leg pain when he was seen 00/00/0000, or when the patient was seen on 00/00/000 he stated he had right leg pain?
As far as the second portion, did the information in the report change from the original visit, or does the report still indicate the same thing as he reads it presently?
Unless I could be positive of the intent of the dictator, I would not change this passage from the way it was originally dictated. As dictated, the passage is ambiguous and somewhat awkward but does not require you (the MT) to make a decision as to the intent of the dictator.
Just my stinky opinion...others may vary.
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