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Serving Over 20,000 US Medical Transcriptionists

IT users?? Need ideas on how to record (sm)

Posted By: Greetings Comrades on 2006-05-28
In Reply to:

the rad report MR#s, DVI#s, Accession #s in IT so to save me time.  This is radiology and at times, recording the exam numbers takes longer than typing the report, so hopefully, you understand. 


My idea is to open a daily list on the blank page of the IT screen and then save it at the end of the day.  Does this sound plausible to you?


Thanks for your feedback! 


Rad MT




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For the record,
the solo-practices and smaller offices are outsourcing to the hospitals...


can anyone set the record for

My record is around 45.  Right now i'm on a report that is up to about 23.  Talk about toxic!


re-record
If re-recording to digital, pretty easy. Play either in handheld or transcriber, and use either computer or digital handheld to capture. Just need the connecting cord between two units - can get at Radio Shack.
if it was in my medical record?

It would depend upon whether or not it could have a negative impact upon my medical care. If the doctor dictated something like, "The patient has diabetes" (when I don't), yeah, I would ask them to correct the record. But for something like what was stated originally ... heck no. Let it stay.

But that's me ... I don't have OCD and I'm not anal retentive about this business like others. Never have been and never will be.

I still think you need to lighten up. There's a lot more to worry about in life than something like that.


expunging record
Just a thought -- a friend had a felony from years ago expunged from her record -- but background checks from then on noted the expungement on her record -- which raised red flags in itself.
another broken record...
me too. It absolutely befuddles me that anyone would be trying to get INTO this field, especially with all the ominous signs that are right out there for anyone to see. I think new moms with babes are just blinded by the idea of "working at home" and can't see the competition they are facing.  Me, I am in nursing school... not an easy job by any means...but I'll be good at it and will find my niche quickly and will always have a job! My biggest account is making noise about getting a VR system. If I wasn't in nursing school, I would be having a panic attack instead!
How did he get his record cleared?
You mentioned that he has a "clean record." I still have this thing on from 11 years ago. Did he have to do something in particular to clean his record or did it just drop off?
We all make dumb mistakes at some time in our lives, eh? LOL
Med Record Retention
That's a very broad question. It's my understanding that the answer depends on the State and the age of the patient at the time of service. Liability required juvenile records be kept forever since it used to be a base could be brought when the injury was first noticed, and that could be well into the adult years.
You have to record to the computer
Get a program like GoldWave (I think goldwave.com). You can buy a plug that goes one end in the transcriber and the other in the computer. One end goes in the transcriber earpiece plug and the other goes in the computer microphone plug.

Then play the transcriber while using Goldwave (or whatever) to record from the microphone input. It creates a WAV file or whatever you specify.
LOL. Did you tell your doctor so he could record it? - NM
NM
That particular patient's record
is still confidential information, thus protected. Who knows, there may be contributing factors about that other patient and that is why the name was mentioned. Either way, if it was dictated to be transcribed and fits with the account specs, it is to be transcribed. I've worked for companies that did and did not allow patient and other names in their records, sometimes it just depends on what the client wants.
Public record
http://www.fbodaily.com/archive/2009/05-May/30-May-2009/FBO-01829906.htm

http://www.fbodaily.com/archive/2009/05-May/30-May-2009/FBO-01829905.htm

These 2 companies were just awarded all of VISN 7. Not sure exactly where the split is. Look on VA website for hospitals make up VISN 7.
Why don't you set the record straight Ms. AAMT?
Why are you sooooooo defensive?
Setting the record straight

You purchased an IN-155 foot pedal for compatiblility with DVI VoiceWav.  (We have sold nearly 1,000 of these with zero returns.)


When you called our toll free 800 number for support we told you that the problem was not the pedal and was either the software you were using or your computer.  Reluctantly, we agreed to do an exchange for you.  (FYI, when your first pedal came back to us it worked absolutely perfectly and still does.  In fact it is plugged into the same computer I am typing on at this moment.  It has been tested daily since it came back with no problems).


Now, you voice incorrect information on MTStars.  Your problem is in your computer.   


Please feel free to call us yet again if this is not clear to you.


Tom Wilkes


President


Executive Communication Systems


(800) 644-9525, ext. 101


It is about CLARITY in the medical record.
It makes the medical record easier to read, which means more accurate patient care
Try expunging the felony record. sm
My friend's daughter did this after being turned down for a job at Target. She was an adult. You will need some legal assistance to do it.
electronic medical record nm
/
A.S. in Medical Record Technology
This included a course in Medical Transcription.  Went to work in a physician's office.  My job title was medical records, but the main component of the job was transcription.  This led to later full-time transcription job. 
It's probably an electronic health record.
They probably got an electronic health record where it is basically a point and click system that creates a progress note, does the coding, etc. I think this is going to hurt transcription greatly.
In Microsoft Word, there should be a record
of changes made and who accessed the report and made it. SOmeone with more technical expertise should be able to tell you what you do.
After 5 years, you can have your record expunged. sm
If you apply for some high-level security position, such as law enforcement, FBI, etc., it will still show up, but otherwise, you can trully answer "no" if asked if you have any convictions, etc. You do have to go through an attorney, and I do not know how much it costs.

Hope this helps.
Let me tell you about falsifying a medical record
I know first hand it has been done and it was done about me. I had plastic surgery (3 part type) with face lift, tummy tuck and lipo in 2002. The doctor "forgot" to do the face lift. Had paid up front and I asked for the portion of the face lift only returned. He gave me an IOU on his office station but then later would not pay me and get this --- 8 months after the surgery he dictated my report, put in the face lift like he had done it along with the other. Now most people would say well, maybe he got you and someone else confused. Not so- this same physician who was head over the plastic at the hospital called me personally at my home, not through his office, but him personally twice in a threatening like voice when I tried to take thru mediation. I worked inhouse at the time and rather than risk my job, I left it up to Karma. This actually happened to me. I went to the lady over medical records, I worked in the same department, and told her exactly what had happened and she said I could write a note to put in the front of the chart disputing it had been done. Unbelievable, huh?
Re-record and C-phone question...sm

Hi all!


If I have an account that requires a C-phone, would I have to re-record it? 


Isn't re-recording very time consuming?


It's been a while since I worked with a C-phone, but I don't remember having to re-record, and I just remember hearing folks on these boards talk about how time consuming this can be and how the sound quality can be different.


TIA for any expertise!


I use / and record a macro which I assign
to an F key. Then I put / wherever in the template I need to input.

So moving around is as simple as pushing the F2 key as many times as needed...

I also use the macro record and assign to an F key functions like block and copy. Then if you have to move a whole section of words to another page, it's one key to block and copy and one click of the mouse to paste and you're done.
Unless you are the primary record-keeper sm

You should dispose of all of them. My rule of thumb for files that I keep on my computer is two weeks. I send them in daily to the clinic, but I do keep mine for two weeks as backup in case for some reason theirs get lost.


You need to dispose of them so that the information can no longer be extracted. I remember a long time ago we had a magnet we would run tapes and/or disks through which would wipe the data. I don't know if those still exist, or how well they actually work.


You might get in touch with the MTSO or clinic or whoever the information originally belonged to and find out how they dispose of their sensitive material.


You need two macros. Just record the steps
to change to higher level, and the second one to change it back. Be sure to assign shortcut keys to each.
Protective of the US medical record???
She employed offshore MTs...how protective could she have been?  Are you kidding me? 
Telephone Record Adaptor
You might want to look into getting a telephone record adaptor that plugs into your laptop sound card.  Also would require audio capture software but then the files would be recorded onto your computer and from there you could transcribe them.
How to re-record off phone line?
Does anyone know how to re-record transcription off a phone line?  TIA
The actual medical record contains
those things you mention. The dictated report sometimes does, not that is not often. Some facilities, however, do have the physician dictate everything imaginable and even if it is 1 out of every 10, that is still too much info to let out.
He did not start the electronic record, really
Why beat a dead horse? I have been on electronic records for years now, before him. I think you are a hater and any and everything you can find to say about him you will. This is NOT NEW with electronic records. Find something else to gripe about, ok?
If the law requires that a patient's record be
protected by HIPAA, and HIPAA laws have no effect overseas, wouldn't it logically be a violation to send the record overseas?
I think that is very unprofessional for a medical record. nm
x
How can I record patient data as fast as possible

Radiology patients, so reports are short most often.  We have to log two several digit numbers, the types of exams (chest/abdomen) dates.  We have sheets to do this on but am thinking I should keep Wordpad open and type in there.


Any ideas on how I can do this and not lose momentum or time?  I do about 100 exams a day.


Thanks!


I still record but not onto tapes.. onto a digital recorder. sm
I use a skutch box hook up to the phone and recorder. Make sure you're muting out room noise, a speakerphone and mute button do the trick quite nicely.
I'm a broken record but I'm riding the train too
I'll just work as a nurse AND run my MTSO until the train falls off the track.
EMR (electronic medical record) and voice

Yes, they are pushing to make medical records electronic, instead of a paper chart.  That doesn't affect MTs.  We still transcribe reports and instead of the reports being printed and filed in a paper chart, they are part of the electronic record and can be accessed at any computer in the hospital , for instance.  The doctor can sit at the nursing station and pull up all the dictated reports, the lab, radiology reports, etc.


 


Voice recognition, of course, is something different.  There is no one saying that VR has to be used by 2012.  That's simply an alternate way of getting the dictation onto the EMR.


Having the assault taken off his record was a condition of his probation. SM

So, I'm not sure if at the end of his probation if he had to contact anyone or follow it up in anyway.  We know it's not on there anymore because he's going to nursing school now and had to get his CNA license as a prerequisite for the prgram and they did a background check for that.


I'll ask him.  He's not here now.  While I'm working, he and my son are at the boat show figuring out how to spend my paycheck! 


Big deal is legal, medical record which should be the
truth, not a made up report. Medical records are supposed to stand in court just as a sworn statement, that is all. I like the truth and that is the way I try to live my life, not a bunch of falsehoods. I guess others can live on lies if they want.
The electronic medical record has replaced MTs at my job..it's all over!

My job has been scanning all the medical records over to electronic medium and the doctors are now taking laptops in the exam room with them and typing in all the info, so basically, my job will be obselete once this transition is over. 


Our boss has been doing a comparison of the clinics who now have the electronic medical record--those docs went from dictating thousands of lines in a weekly period to less than 50!!!  Of course this is a tremendous difference and it's "lights out" for us MTs.  We've got about a good year before it's all done.


Have any of you been affected by this new technology?


P.S.  I didn't care so much anyhow...I hate this industry and this job, so I've been looking for other employment anyhow. 


 


 


Longest ER exam on record! My funny for the day.

"She states she has had right-sided abdominal pain and she points to her right lower quadrant for approximately three days."   


I wonder if her pointy finger got tired!!!


You don't want to record, takes a long time and unless you

are making big $$ you won't make any money.  Also, if you forget to rerecord header info you're out of luck.


You can get an adapter from Radio Shack for about $15 and rerecord to a cassette player, in which case you'll need a transcriber, or record to your computer and I'm not sure how that is done.


As I stated last week when you asked this question, you need to look into digital phone service, something like Vonage, or most high-speed internet services also offer it. 


You could also buy prepaid phone cards at Sam's Club, where they are fairly cheap, but you're still talking about $100+/mo.   My digital phone is $34.95/month and you can keep your landline or switch it to digital, which is what I did. 


 


 


If ADHI gave a rat's @$$ about 'medical record
If their 'cash cow' (India) ever starts to wise up and run dry, like America is doing now, they'll be out of the MT-biz unless they can find another 3rd world workforce to take advantage of.
NDMT, to record your own keystroke macros, SM
in SH: While you're typing, hit ALT+Insert, type a name for your macro on the first line that says "keyword," then hit ALT+R to turn on record (or hit the record function on the right side with the mouse).

Then just type the Keystrokes of your correction. When you're done, use your mouse to hit "stop" on the little window that's waiting in the upper right of your screen. Or hit cancel if you goof up, and you'll be able to try again.

Here's one to try: To back up, insert a period, space, and type "The" to start a new sentence (how many times do you do THAT to break up runons in a day): Turn on "record," position your cursor at the beginning of any word and type those keystrokes (back up to the word behind, hit period, space bar, and type "The"). Then hit "stop." I named mine ".t" (one guess why).

The only trick to remember with this is one more thing. After you hit "stop" it takes you to the first box you started with. With your cursor still positioned at the very end of your new macro string, use your mouse to open "tags" on the bottom left and choose "nospace." That keeps it from auto-adding a space at the end because you already usually have one there.

In case your system doesn't provide you with a macro for changing the case of a letter, here's one you'll find very helpful to copy into your macro text box instead of recording it:

{@NoSpace}{@KEY Shift+Right}{@KEY Ctrl+Alt+C}{@KEY Left} I named this one "F" because it's right under my index finger. Flicking that key (and activating by hitting "Enter" or whatever key you're using) changes the case of the letter it's to the left of--lower case becomes upper, upper becomes lower.

And here's the one you asked for to copy the preoperative diagnosis under a postoperative diagnosis heading:

{@KEY Enter}{@KEY Up}{@KEYDOWN Ctrl}{@KEY Right}{@KEY Right}{@KEY Right}{@KEYUP Ctrl}{@KEYDOWN Shift}{@KEYDOWN Shift}{@KEYDOWN Shift}{@KEY End}{@KEYUP Shift}{@KEYDOWN Ctrl}c{@KEYUP Ctrl}{@KEY Right}{@KEY Enter}{@KEYDOWN Ctrl}{@KEYDOWN Ctrl}{@KEYDOWN Ctrl}{@KEYDOWN Ctrl}{@KEYDOWN Ctrl}{@KEYDOWN Ctrl}{@KEYUP Ctrl}{@KEY Ctrl+B}{@KEY Caps}postoperative diagnosis{@KEYDOWN Shift}{@KEY Ctrl+B}:{@KEYUP Shift}{@KEYDOWN Ctrl}{@KEYDOWN Ctrl}{@KEYDOWN Ctrl}{@KEYDOWN Ctrl}{@KEYDOWN Ctrl}{@KEYDOWN Ctrl}{@KEYDOWN Ctrl}b{@KEYUP Ctrl} {@KEYDOWN Ctrl}v{@KEYUP Ctrl}{@KEY Caps}{@NOSPACE}

You use this with the cursor positioned at the end of the preoperative diagnosis. It only works if the heading is "preoperative diagnosis:" I'm pretty sure there are better ones available for copying if you look.

Have fun trying a couple out. I think you'll find them addictive. :)
Sorry about link - it's in the Greensboro News and Record sm
I asked my tech support person at my job, and he said I'd have to contact Time Warner to see how much I use it. I'm sure they's be happy to provide that info (that was sarcasm).
You proved my point.. Most active ON RECORD, which is but a blip in
x
i personally would not want my boss typing my medical record either
nm
Lets set the record straight, email was concocted
enough already
ALL of the clinics I work on use SS #s as medical record numbers, and many of them cc to the
patient at their home address, which is conveniently typed at the bottom of the report.  Seems pretty straight-forward to us, then why can't the govt figure this out and put a stop to it?
RE: Can someone tell me what the site is to check on a doctor's credentials & record? nm
\
Approve what? The information used is already part of the medical record and, therefore,...sm
has already been approved or authenticated or whatever one wants to call it.