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ALL of the clinics I work on use SS #s as medical record numbers, and many of them cc to the

Posted By: Babs on 2006-01-22
In Reply to:

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?


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    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.


    It is about CLARITY in the medical record.
    It makes the medical record easier to read, which means more accurate patient care
    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. 
    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?
    Protective of the US medical record???
    She employed offshore MTs...how protective could she have been?  Are you kidding me? 
    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.
    I think that is very unprofessional for a medical record. nm
    x
    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.


    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. 


     


     


    i personally would not want my boss typing my medical record either
    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.
    again, making medical record digital does not affect us.
    nm
    Have MTSO's or IC's all become electronic medical record suppliers as well as transcription pr

    I've been an IC for over thirty years and the medical offices are now asking me if they can search for old records?  What, they don't keep their own records anymore?  Do all MT companies now offer searchable databases on their company servers for the physician's staff or do they install databases on the physician's computers for this sort of thing?  I've been asked to provide this and I'm thinking "wow, can't the office staff open word and find the appropriate folder and file?"  Is this now a standard item offered by MTSO's?   What happened to medical office management software?  Are transcription companies now becoming electronic medical records suppliers?  If so, please let me know.....If so I've become a dinosaur!



    So true, work for some doctors and clinics also and many are now
    jumping on the save lots of money and offshore bandwagon! We just can't win. It's over everyone :(
    Usually work "live" on a Cphone, while connected. There are ways to record & work off line, bu
    s
    I have 2 clinics still on tapes, love'em! Also work for a national. Like that too. nm
    nm
    *67 doesn't work on 800 numbers
    Corporate numbers, 800 numbers, and government numbers often use a different form of caller ID. It's called a WATS line, and it records the originating phone number of EVERY call, not just the un-hidden ones.

    Do this instead, if you decide to report something anonymously:

    Go to a Dollar General, Family Dollar, whatever, and buy a Tracfone for $10. Activate it online from a public WiFi spot such as Panera's (NOT from your home desktop computer).

    Use the Tracfone to call the 800 number. Throw away or give away the Tracfone after that - don't use it for anything else. Remove the battery immediately after the call. Place the call from a location as far away from your physical location of residence as possible.
    The place I work already offers 800 numbers for all
    inside accounts and most outside accounts as well. Not all are not good to the MTs.
    I've had plenty of work, though the numbers on my
    account are way down, some accounts not affected at all.  Easter was early this year and coincided with spring break in some areas.  You'd think that there would be MTs taking days off too and that would balance things out. 
    I still work there and so do many others who have spoken to attorneys. See link inside for numbers.
    http://deflaw.com/
    If they pay by character, they pay for numbers. Numbers are characters, silly.
    x
    Does anyone work as medical coder who
    can answer a few questions?  1) Has anyone transitioned from MT to coder and, if so, how does it compare salary-wise? 2)  Can it be done at home as MT can?  3) How long to train and ease of securing job as newbie?  There seems to be a big demand these days in comparison with MT jobs.  After 15+ years as an MT, I'm wondering if that would be a better way to go??   Would appreciate any info!
    Medical Malpractice lawyer work

    I've read here before about some MTs who work for RNs transcribing their notes for medical malpractice lawyers, particularly in So Cal.  If anyone out there can give me more info such as need, what to charge, how to find, etc, I would be so grateful---I'm an MT/editor/quality auditor with 10 years' experience needing to make more money out of my skills.


    Thanks!


    Does Shorthand work with Medical Spellcheckers?

    Just getting to know the Expander program "Shorthand", and saw that it says to shut off all spell-checkers.  Does that mean that I cannot run Spellex or another Medical Spell Check program with it?  Has anyone any suggestions as to what they use?   Or any "work-arounds" 


    I am just getting started and trying to decide if I like "As-U-Type" or "Shorthand" better as my word expander.  It seems that "Shorthand" does not act like a spell-checker like "As-u-Type" does, so need to add one.....preferrably a medical one.


     


    If it is a medical office, they should have one as we all sign one when we work there -- nm
    ...
    I currently work for Accustat LLC but got an offer from Cort Medical
    Does anyone know or have any information about Cort Medical?
    Yeah, but medical personnel who actually work directly with
    patients are a bit "different" like that. They think nothing of taking a look or having a touch here and there. And the morbid senses of humor many of them have. My friends from high school are both RNs now, but they're like that.
    I seriously doubt that type of work is as complex as medical reports.
    nm
    Yes, it's Independent Medical which are normally work comp related and Looooooong...
    but very interesting.
    Could maybe see clinics going over to
    full EMR with doctors documenting, but it would be very hard in hospitals for physicians to do this considering how complicated some dictations are.
    Try hospitals and/or clinics-
    I don't know about other places but in at least 3 of the major hospitals in my area they have people work both in house and at home. Everyone works in house to begin with and has to prove themselves before going home. Some people (like me) just prefer working in house, so it works out.
    Local Clinics
    I would seriously try to find work at a local clinic if you're finding it hard to get hired with a National. I also went to a local community college. I didn't take me long to find a very small local MTSO to hire me, thank God they decided to take a chance on me. I now work for a local nephrology clinic. I definitely know though that if I tried to go out on my own, there would be no way I could have done it. Good luck with whatever you decide to do.
    Yup and I love my clinics! nm
    nm
    Try local clinics
    Or if you have a small local MTSO, they may be willing to give you a chance. That's how I started. I trained with the MTSO at her office for a couple of weeks and then I started working from home for a local nephrology group and I've been there for the past five years. Try not to get discouraged, although I know that's a hard thing to do.
    That is great if you can get the same dictators. I have over 85 and all different clinics. (sm)
    That is why I started my own business. It really depends on who you work for and if you get a great account your lucky. I unfortunately wasn't that lucky and after 15 years a GF and I do it locally for doctors. Much less stressful. Glad you can do that!!
    I wish more hospitals & clinics would get the picture that (sm)
    what you have just described is the best and most cost-effective way to get quality transcription. At the hospital where I used to work, MTs are treated like the scum of the earth. The nationals want us, but pay peanuts. By eliminating the middleman and the overhead of having enough office space for MTs, a hospital/clinic can pay the MTs what they're worth, the MTs can afford to keep working for them and stay on for many years, gaining a better knowledge of the doctors and the institution. Both that and having decent pay and a more flexible schedule means happy MTs, and happy MTs will go the extra mile to produce top-level work. It sounds like your employer is ahead-of-the-curve in the way it deals with its transcription needs.
    I think the MDs that care in their offices or clinics sm
    keep their trans in-house. My personal MD does and overseas every last little detail and she is tough! The ones who dont want to mess with it go to a service and let the service take responsibility. So neither will care....IMHO
    try local hospitals/clinics around you
    that still have in-house. My local hospital did this and the education/experience/hands-on help provided was golden. Then go home and work - you will be viewed as a step up if expierience is in-house.

    DO NOT pay for mentoring.
    I would try local doctors and clinics
    I only work weekdays and nights only when absolutely necessary, no weekends or holidays either.
    Hospital with many smaller satellite clinics associated with it
    nm
    I am an IC and my accounts are clinics and doctor's offices

    So I have weekends off unless the docs dictate late on Friday, in which case I have the choice of working late on Friday or getting the work done over the weekend.


    With clinic work, you don't have the constant flow that you have with a hospital. You can't work harder or longer hours to make more money. There is a specific amount of work, and when it's done, that's it. Your income will fluctuate. But if you're willing to put up with that - you can have your weekends off.


    Is this Holiday a major one? Clinics and offices closed?

    I guess I am out of it.  How big of a holiday is this?  All the kids home from school today?  Post offices and banks closed?  Seems rather quiet work-wise.  Wondering if I should start cleaning the house or keep staring at the no jobs to do in my queue.


    Thanks!


    TO the person who emailed me about their experiences on the multispecialty clinics, etc.
    I tried twice to respond to your email and help but it keeps coming back undeliverable.

    ??

    good luck getting hospitals/clinics and the med communityto
    nm
    Yes, I always have the notes. One time, it was an entire day worth of clinics except for one!

    How did they just get one note and not the rest?  There have been a couple of times when the doctor just didn't dictate on that particular patient, but most of the time I typed the notes, printed and delivered the notes, and then they say they never go them!  And I always have them on my PC and backed up on CD.


    I'm just putting my clinics on digital too, check out enclosed links - sm

    http://www.hthengineering.com/sst2.html


     


    http://www.hthengineering.com/pdf/DigitalGuide.pdf


    Check around your local area for clinics or transcription companies
    That's what I did. I first started out working for a very small MTSO and worked at their office for a couple of weeks and then they moved me home and I started working on a single speciality account. I'm still working for the office after 5 years (altough the MTSO closed her business).
    I would buy new a Dorland's Medical Dictionary, Stedmans Medical and Surgical Equipment...SM

    and Tessier's The Surgical Word Book, 3rd edition.  Books you could buy used I would say would be Stedman's Pathology and Lab Medicine and Cardiology/Pulmonary word book.  These are all the books I use the most during my day.  You could buy other speciality word books as you need them and could probably go used with those.


    I wouldn't bother with buying a drug book, new editions come out every year and I just stick to the FDA website and RXList as my drug references.


    Also FYI, not a book, but I use my Stedman's Electronic Medical Dictationary a lot.  It's easier to open the program than it is to pick up a huge 30-pound dictionary.


    Any hospitals/clinics hiring home-based employees on an hourly basis? TIA

    /