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Basic 4 hospital work - history and physical, discharge summaries, operative notes, and consults. nm

Posted By: just me on 2006-06-03
In Reply to: Acute care - Orianna


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  • Acute care - Orianna
    • Basic 4 hospital work - history and physical, discharge summaries, operative notes, and consults. nm - just me

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Hospital work: Op notes, Discharges, Consultations, History and Physicals. nm
Acute care is considered hospital transcription - discharges, history/physicals, consults, and op
It's hospital work. The basic four.
because the larger companies can handle the larger hospital accounts.  Acute care just means hospital work as opposed to clinic, which would be physician offices, i.e., family practice, cardiology, nephrology, etc.
history and physical
H&P = History and Physical.....

H&P = History and Physical

It is one of the "Basic 4" reports also.

Basic 4 = HP, Consults, DS, and OPs.
Acute care may contain ER notes if you are lucky, but will usually contain the basic 4 plus more procedure notes like cardiac studies, and a wider mix with wound care clinic notes, possibly rad-onc clinic notes, just depends on the hospital's specialty. Or the terms can be used fairly interchangeably.

The main focus of hospital work is the basic 4, but on some accounts they will say with OP notes and others without OP notes, because (I believe) some MTs will sign up to just do OP notes because they are their favorite. With a smaller hospital you are more likely to have a mix with little departmental procedures, IME, and larger hospitals tend to just have a service do the basic 4, again, IME.
Acute care would be a history and physical or
A clinical report would be what a physician dictates from his office when he sees patients.  Sometimes, it gets sketchy with outpatient surgery clinics.  Acute care is usually work dictated from a hospital setting and clinical work is dictated from a physician's office, which could be a cardiologist, urologist, etc. 
Mostly inpatient hospital dictation - H&P, DS, Consults, Ops, some include ER
and progress notes. Acute care is usually inpatient dictation from hospitals.

Hope this helps.
physical therapy work
I have been doing neurosurgery/neurology for the last 8 months and my boss would like to move me to a physical therapy account. I know these are totally different specialties, but I was wondering if any of you can tell me if physical therapy is really difficult to learn. It took me 3 months of intensive training to learn neurosurgery. There will be no training for this position. I really want to try something besides neurosurgery but am hoping it won't be a huge transition for me. Any encouragement would be great! Thanks.
most psych work is included in multispecialty hospital work..sm
contracted to a medical transcription service that requires multispecialty experience because of the hospital work. Unfortunately, very rarely can a medical Transcriptionist these days be given only one specialty when working for a service or hospital. We have to be well versed in multi specialties. The Turn Around Time on demands have increased, and thus the service or hospital gives the MT many different types of work. Learn as many specialties and gain as much experience in different specialties, which in turn will make you a more valuable MT and more apt to gain employment.
It is hard to transcribe radiology notes as compared to usual notes?

Can a new MT without radiology transcription experience be able to do it?

If work @ hospital is low SM
and they have their own transcriptionists, they are probably saving the work for their own people.  In the priority list is making sure the hospital transcriptionists have work first, then the service.  Probably if you are fairly new and their are other MTs working on your account at the service, they may have priority over you as far as work distribution goes.
Try to get a job in a hospital. Don't try to work at home for a few years of doing this full-tim
The operative word being SOME...but not very many
I did not come across one company in my extensive search for employment that began before I graduated from Community College that stated they would not let me test because I didn't go to one of the "top 3".  In fact, most companies have links to their testing on their websites.  Those that don't will send you an email with the proper links for testing purposes.  To keep stating that the "top 3" schools are the be all and end all to successfully obtaining employment in this field is just plain wrong.  I was hired before I even finished school.  It depends on the determination of the person.  Two different people can come out of the same MT program and one can be an excellent MT while the other can be absolutely horrible.  Being a graduate of the "top 3" has nothing to do with it.
H&Ps, Consults, OPs, and DS
physical examination.....
Go to:

I found this site a while back. I'm pretty experienced, but I thought I'd check this site out for a friend of mine, a new MT.

Hope this helps!
Physical Exam

Does anyone know of any good sites (or books that are not too pricey) that describe the steps of a PE?  I have found bits and pieces here and there, but nothing that puts it all together. I type for orthos and sometimes they lose me on the provocative testing words.  I am mainly looking for PE samples/explanations for things like: knee, shoulder, hip, wrist, ankle.  I have a reference sheet that states their normals, but sometimes they do a test that isn't on the sheet and of course that is when they mumble and I just can't hear it properly. I think it would be helfpful for me to be able to picture the steps of the exam as they are dictating them.

Thanks for any ideas!


A few notes below:
1. Be consistent with training.
2. Use the BOS appropriately.
3. Offer all types of dictators, especially blubberers, ESLs, whisperers, hackers, and speed talkers.
4. DO NOT GLOSS OVER the realities of this profession, especially financial gain.
5. Be supportive but let us know that we are not going to be professionals right at the start. This only comes through training, dedication, a willing to listen to QA comments and implement them, love for the profession, and years of MTing under your belt

maybe take a medical term course and start with physical therapy office
Progress Notes

Well I did H&P's along with various specialty progress notes. So would I be considered Multispecialty? I've only done H&P's, consultations, and some discharge plans. No Op Notes. Which is better to pursue? Acute Care or Multispecialty?


Has anyone ever used Notes Link?....sm

Sorry if this is on the wrong board.  I am starting a new job that will be using Notes Link.  I have never used this platform.  I would appreciate any good or bad news about it or even some hints.


Soap notes
I just finished taking another employment test. I think I failed. Does any one else have trouble with soap notes? My school didn't give us much practice with those.
Soap notes:(
I figured it out. Thanks for all of the help.

I love doing psych notes
they do tend to be boring, but are usually in pretty plain English and are pretty long, so you get lots of lines. Easy money.
We are suppose to be using Notes Link. I have never used it before so I am not sure how....sm
friendly it is. 
basic 4 is
OPS, Discharge, H&P, and Consults (hospital notes)
Basic 4
What does the basic 4 consist of?
Basic 4
Just wanted to be sure what the basic 4 is referring to.  I think it means like ER, h&p, radiology or something like that?  Thanks. 
Basic 4

History and Physicals

Operative Reports

Discharge Summary

Clinic Notes

are the basic 4

Are these the basic problems with MQ?
Is it that the grumbles with Medquist from MTs that they put in voice recognition software? That technology sucks everywhere. Everyone who does voice recognition has to clean those suckers up, it's awful and very time consuming. Is that along with the fact that supervisors are not as attentive (or in some cases too attentive) the main problems?

I am looking to hire on with a company for the long haul and possibly retire with (or at least reach social security). I don't need a mansion on a hill or a brand new double wide in a park. I just need a basic, dependable MT job that I can count on for being able to earn a regular paycheck.

In some threads, I get the impression there are too many chiefs and not enough indians. In other threads, I get the understanding that there are too many indians altogether, therefore not enough work to go around. Across the board I get the understanding that the "higher ups," for lack of better words, don't communicate well between themselves or with the MTs. Could someone at least tell me if that much is correct?

learn the basic tricks. sm
learn how to set up templates with field codes (F11 to jump).  Learn how to set up your expander.  If you don't have a clue look into the ABCZ system.  Use Google to search for information on this.  If you are stuck using autocorrect instead of a better Expander learn how to enter words quickly w/o a mouse (alt t a to open it. then tab then enter).  These will save you a LOT of time entering or editing your entries.
Very basic question about x-rays

Can someone clarify this for me.

When the doc states, "X-ray, AP and lateral" - Does it mean that the x-ray was taken front to back (AP) and in the lateral plane?

For a while I was thinking that AP was one film and lateral was another, but  I wonder, because the docs keep saying "shows"  (indicating by their grammar that it is one film) instead of "show". I feel kind of dumb not knowing this. I looked in my reference that describes all of the different ways to take an x-ray but still can't clarify it.


Acute care is also called basic 4, which is

H&Ps, discharges, Ops, and consults.  Clinic can vary from a doctor's office to an in-hospital clinic.  The in-hospital clinic might be a little more technical than an office and the format may/may not be similar. 

In my experience clinical is not a lot of medical terminology and the drugs tend to be the same ones over and over again.  I liked doing clinic work in that I knew what sickness was going around and what the recommended course of treatment was.  With clinical dictation you also tend to have the same doctors every time so you get to know them and can make lots of normals, which will have you producing more lines.  It can get boring though to have the same person over and over. 

The line rate is usually higher for acute care too. 


Just type what you hear. Lots of things are repeated in differnent notes.
Don't worry - you'll learn all that basic stuff
in school. They used to teach it in secretarial classes, of course, but if you know you want to be an MT, go to one of the top schools (M-Tec and Andrews), and you will be ready when it's time to test.
I've mentored AHP newbies, too, and they lack SO much basic
hospital pay
I inquired in my area (Southwest Michigan) and one of the hospitals told me they pay $11 - $17/hour.
I want a job in a hospital sm

Do they usually post their help wanted on their websites, or do you need to know someone to get in??  I see ads all the time for work at home positions, but what about office positions?


Starting pay in hospital
Any ideas of the pay for in the hospitals?
RE: Starting pay in hospital
Depends on what part of the United States you are inquiring?
hospital transcription

Ok I have looked at hospital MT jobs in AZ and all of them want experience and almost none of them pay well or even list pay in the ad, your best bet is to look on monster.com or try the specific hospital site. for example a big hospital group in AZ is Banner Health, they have their own website and job listings, so try that direction.



I don't live where the hospital is looking - sm
I actually have two hospitals to recruit for - one in NY and one in Maryland. I will have another soon in Minnesota after I fly up there on Wednesday to find out their needs and look at the surrounding area. These would be for people wanting to relocate. Relocation would be paid.
depends on the hospital
There is hospital near me who will take on beginning MT's who have typing and medical terminology skills. They work with you for up to a year before you go on your own. They pay about $11.75 an hour to start. But, then there is another hospital that requires years of experience. You need to check with you local hospitals to see what their requirements are.
No, it's not your job - when I worked in a hospital (sm)
I was paid hourly with bonus for production.  Therefore, we could occasionally do other work (like the charting) if the clerk was off, answering phone, etc.; but being strictly on production, I would say, no it is not your job.
working in a hospital
I work for a hospital and have for 20 years. I am an at-home MT.. I am a full-time employee just like anyone who has to physical go there everday. The pay is much better and benefits too.. There are some still out there.
VA Hospital transcription

Does anyone know any MTSO who has VA hospital accounts?  I ran across a great ad looking for MTs last year, but did not have enough MT work experience yet to be considered and was told to reapply when I had more experience.  I don't recall who this company was, but was intriged by the ad for MTs and would like to follow up and at least apply.  I saved the ad, but can't find it at present.  One of the things that interested me most was that the company sounded like it really valued its MT workforce.  I am looking for a company to move to and stay with for the long term.

I would appreciate any information anyone can give me.  My experience thus far has primarily been with hospital accounts and I am currently doing ER editing and standard.  Thanks.


working in a hospital

If you have the opportunity to work alongside another MT in a hospital, TAKE that opportunity.  It will be much easier to learn with someone available to help you right when you need it instead of waiting on e-mails with corrections or using IM. 

in-hospital positions
You may have already, but also check out indeed.com. They have sometimes in-house positions also.
So I'm still not sure ... but the MT is a hospital employee, sometimes they will "weight" m
dictators so you get a little extra credit for unusually bad dictators. But that may not be a common practice everywhere.

If you are an IC, or at least once you are experienced, you might be able to negotiate a better rate for a particular MD if nobody else can or will do his dictation.

But have faith - some dictators who sound just horrible the first few times will suddenly be a breeze once you "crack the code." You will probably do that much more quickly if you have an experienced MT helping you out, listening to the difficult spots.

Have you tried your local hospital or physicians?

I work for my local hospital and my supervisor hired "newbies" all the time.  However, some clinics or hospitals require you to do a little onsite time before going home, at least mine did.  I had to meet a certain productivity rate and QA rate before I was "turned loose". 

I'm not sure if you are wanting to work for a national company or not from home.  Since I have no experience with that someone else may be able to guide you in that direction.  I just know around here, having tons of experience isn't really needed to be hired locally. 

Only if this hospital will employ you when you're done. That