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Question about verbatim... How far are we supposed to go with verbatim? - HRN

Posted: Nov 19, 2014

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 will probably ping me and I'll gladly take the hit as long as the QA puts her initials on the report next to mine when she is finished, but this is an ESL dictator who probably doesn't realize the word he has chosen is vulgar slang and there are better, more professional terms he could use to convey his thought that the patient sounds bad. I would be interested to hear other opinions on the matter.

I would have transcribed the word just as it was dictated. - MT

[ In Reply To ..]
The dictator is the one signing off on the document and I'm being paid to transcribe whatever they say.

Actually we are being paid to produce a legal medical document. - HRN

[ In Reply To ..]
We are being paid help the dictator organize his thoughts in a concise and coherent manner by utilizing our education (medical terminology, English, etc) and experience.

I'm not sure why the moderator moved my post to the Word help board when clearly I'm not asking for help, but more looking to discuss a general issue that affects the MT industry as a whole, but whatever....

Doesn't sound like you are interested in either opinions or what your employer wants. - zippy

[ In Reply To ..]
In your first note, you said you would probably be dinged by QA, which says to me that you are fully aware they won't like YOUR decision. Then you consulted your peers and got an independent opinion that you didn't agree with. You need to ask your employer/QA this question and get a definitive answer.

This job isn't worth the mental sweat equity.

Actually, if the account is verbatim you are being paid to produce exactly what the dictator - dictated

[ In Reply To ..]
And the moderator moved this to the word board because you are inquiring about a word as regards verbatim dictations.

If uncomfortable with the word, you could have blanked it--sm - anon

[ In Reply To ..]
Personally, I do not think that comes into the realm of profanity and even if the doctor did not attribute it to the patient, it may have been the patient's choice.

No doubt though, if it was a verbatim account, then I do verbatim, whatever the doctor says.

I hope you never have to do psych reports - sm

[ In Reply To ..]
The "F" word is every other word when the dr is directly quoting the patient. Heavens to Betsy, what will you do?

what I do - StillAnMT

[ In Reply To ..]
When I come across words like "crappy," and in the context you gave, I put that word only in quotes. Hope that helps.

"crappy" :) - LadyWriter

[ In Reply To ..]
Agree with StillAnMT...it's always been my policy to put foul language or other slang in quotes. Matters not to me who (doctor or patient) used bad language, but it's still part of the medical record as dictated.

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.. ...

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nm ...

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/ ...

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