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Clinic notes questions

Posted By: jmr on 2007-08-16
In Reply to:

I see lots of jobs looking for clinic notes. I have only done acute care. What exactly are clinic notes? Are they office visits by specialty? Also is the pay for clinics typically higher, lower, the same for acute care?

Thanks.


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clinic is not walk-in or ER notes; it is clinic
could be a small clinic with just famiy practice, internal medicine, maybe physical therapy, or it could be like mine, large, every speciality, cardio, nephro, neuro, ortho, endo, surgery, ENT, podiatry, ophtho, derm...
I think clinic/ ER notes sm

would be a good place to start, either working as an IC/employee for a national or getting your own accounts.


 


Good luck!


Do you get more LPH with clinic notes or Ops? nm
x
only clinic notes can have
an actual name in a report.  hospital reports should never have an actual name but instead just have * the patient *.  hipaa rules.
Yes, it is clinic notes...sm
I also have an extensive list of Expanders that I wouldn't doubt was well over 20,000. I've been building it for the last 11 years working at home. I don't even type out the word with (wi).

I appreciate your response and the boost.
Clinic notes

Mostly clinic notes from my experience:


S - subjective


O - objective


A - assessment


P - plan


 


Clinic notes
I have always done acute care.  If you get a good line rate, could you make good money doing cardiology clinic notes.  I was not sure since you have letters too. 
I do clinic notes...sm
Clinic notes are a lot easier to do. The letters are very easy. If you have good rate of pay then you should make as much money. I do general surgery clinic notes and letters. The only problem I have with clinic notes is you will run out of work. It is according to if it just that one clinic or not you work on. But they can only see so many patients in a day. And if they do surgeries to then they aren't always in the office to see patients all day. So I don't always have enough work. But to remedy that I have another job too. So if I run out on one I work on the other. But if you have plenty of work there is no reason to me you couldn't make good money. My problem is just having enough work.
I do clinic notes also
I love them. They are very easy and I have a lot of normals that I use. I don't have any problems keeping busy with work. The doctor's I work for sometimes see 50 patients a day total. And I don't worry about having no work because I'm an employee and if there's no work I still get paid.
I think clinic notes are boring, you have the same

number of doctors usually and for the most part there isn't a lot of medical terminology and they have lots of normals, which is good because they you can have lots of macros/expanders to help, but I like learning from my dictation.  With clinic notes I did know when viruses/illnesses were going around and what the standard treatment was, so I could try some of the same treatments if we got sick without a doctor visit, just after a while they were just boring.  I much prefer acute care. I have lots of dictators so I don't get sick of hearing one doctor all day, although occasionally I do get a slew of the same dictator, the terminology is constantly changing, new drugs, new equipment, new procedures, etc.


 


Some have said clinic, some op notes, some ER, depends on what you
s
Depends on clinic notes, sm
I really think it depends on the type of clinic notes you transribed.  I went from transcribing very detailed and lengthy multispecialtiy outpatient clinic notes for a major teaching hospital to transcribing acute care, mainly op notes, for another hospital, and it seemed to make the transition, although I felt very confident after about 3 months.  But if you were transcribing clinic notes for just a regular outpatient clinic or clinics (well child checkups, lots of cold and flu, etc) you may have a longer transition period.  It really just depends on whether it's a teaching hospital, the number of dictators, etc?  You CAN do it though--it is all a matter of mindset.  If it IS a teaching hospital or they have an ophthalmology department, I would definitely recommend getting the Stedman's Ophthalmology book.  That made my transition SO much easier, that book, and the Stedman's Equipment Words.  Good luck.  Just give yourself 3-6 months to get acclimated to the op notes, number of doctors/residents, etc., don't pressure yourself to get it right away, and make copies of each report for every dictator--it will save you in the long run because they usually say the same things.  Good Luck!!
I do much better $ wise with clinic notes
I have local office accounts and also work part-time for a national. The repetitive nature of doing the same dictator day in and day out increases my production at least 30-50%; more expanders, more normals, familiar terminology, etc.

Right now I am averaging $25.00+ an hour on my local notes, and less than $12.00 with my national acute care. I do have more taxes and such with my locals as it is 1099 income but I still come out much better on clinic notes.

good luck!
LOVE clinic notes
I do clinic work and I LOVE it.  I transcribe for 3 docs.  There are 4 girls on the acct.  And we ALWAYS have work.  When I am bored on Saturdays or Sundays, I sit down and type for a few hours.  Rarely is the server empty by Monday morning.  I have never been at a loss for work.  It is so repetitive and easy.  Each doctor has his own way of talking and I have tons of shortcuts for each doc in my autocorrect in Word.  So easy, so fast, so fun!
Clinic notes are less detailed normally
than acute care/hospital reports. They are limited to that 1 speciality with only sparse mentioned normally of other medical conditions not pertaining to the clinic visit. However, in acute care, you have to be aware of drugs, generic versus brand, correct dosages, all types of medical conditions, problems, side effects, lab values (a working knowledge of correct and invalid values dictated in case the doctor is in error), and "all" specialities. That is just a few of the things required for acute care transcription.

Many MTSOs looking for acute care MTs will not consider someone who has only been in a "clinic" per se because the MT has only been possibly working in 1 speciality. You need a broad overall knowledge to work in acute care as you never know from 1 report to the other what is going to be thrown at you. In the clinic setting, the MT can be isolated from anything new that has cropped up, especially if in a clinic for a number of years.
clinic notes to acute care

Has anyone gone from doing clinic notes for different specialities to acute care in a hospital?  I have been a Transcriptionist for four years and lost most of my work to India.  I went back to medical billing for about 5 months and have been offered a position to work at home for a hospital.  I never did hospital work.  This will exclude lab and X-ray reports.  I am a little scared.  Any good sites to brush up on for documents or any words of wisdom?


Thanks!!



I was getting $3 a page 12 years ago. But $2 might not be bad for VERY short clinic notes.

Whew! I just left clinic notes after 4 years..sm.
and got back into acute care. My momentum is back and I feel like I'm part of the medical process again. I guess I just like acute care better. I can never go back to clinic notes. I can't deal with those 20-second charts. Took me longer to get in the chart than to type it. The company I WAS with had such a screwed up demo screen if you made 1 mistake you got put on probation. Just toooooo much for me.

IMO, that is.
Wow, 600 lines from 30 minutes of clinic/chart notes - sm
The most I would squeeze out of that would be 350 probably. You must have one fast talking doctor. You are also very fast if you can do 600 lines in one hour, or else you have it macroed/expanded to death and there is very little actual typing so that is why you can do so much in such a small amount of time.
I am working today but i don't get extra pay. just behind on clinic notes and trying to catch up
between cooking.
It is clinic ortho notes , same doctor, very easy dictator
I am supposed to be p/t and he dictates between 30-50 min a day, many times 50-70 min even. It takes me many hours since I am a newbie. The paychecks just don't seem worth it for the amount of time that I am putting in.

I get close to 9 cpl as an IC doing clinic notes. No chance of raise unless I find my own accounts
x
How would you handle clinic notes coming up missing after you've delivered them to the facility?

I type the clinic notes at home, print them, verify the all notes printed, place them in a manila envelope clearly marked with the clinic name and dictator doctor's name and date of clinic.  I then deliver the notes to the lead Transcriptionist at the hospital which manages the clinics.  She in turn distributes them to the clinics. 


The last two weeks, I have gotten several calls from the lead MT that I give the work too that clinics are calling saying they are missing certain notes from certain days which is impossible because I type all notes for a specific day in one large document and print them out together.  There is no way that some are printing and some are not.  Plus I ALWAYS verify that each note printed.  Today, she called and said there were missing notes from two different days.


Then there is the issue of my work being typed by someone in the hospital.  When I deliver work I get a print out of what's on the system as far as clinic notes.  It is a worktype specific list that only I am supposed type.  There are a couple of doctors who dictate all their notes in one looooong job.  There were two very long jobs on my list, but were never pooled to me.  When I enter the specific job number, it says they have been transcribed.  In one instance, the dictator dictated half on one job and half on another.  I typed one job and the other just magically got transcribed.  When I've called to ask who's typing these reports, no one seems to know.


These ladies in this particular transcription department are not a friendly bunch.  I have felt that they sort of resent the fact that I am doing work from home while they have to come in and type.  I think they are wondering why they aren't allowed to work from home.  The work I do is very easy clinic work and would be pretty easy lines for one of them to do just to pad their line counts.


I have a meeting tomorrow with the HIM director who contracted with me about TAT and I know they want a shorter TAT than the agreed upon 24 to 48 hours and I know she is going to want me to make more deliveries than the three I do a week now.  I have asked that they set up a remote printer for me so I can print from home that way delivery isn't an issue anymore, but they act like this can't be done which I know it can be done.


I'm about to cut this account loose, but it's such easy work.  It's just that I'm running into brick walls at this place.


 


Thanks for listening to me whine! 


My mistake, I am not thinking tonight, I actually make 11.5 cpl, clinic notes. I earn my money thou
nm
And you'll almost never get just Op notes. Probably get mixed acute care - op notes, discharge su
s
Meditech questions and Cerner questions. Any input is appreciated. SM

I just recently went back to work in the office at a local hospital. We type in both Meditech and Cerner, depending on what you are typing, i.e. Medical Records reports versus Radiology.  We are currently typing blindly in Meditech, meaning we do not have access to our line counts and must depend on management to give us our totals.  In Cerner, we are able to run a line count report and print out a hard copy of our line counts at the end of the day.

We are finding that 800 lines in Cerner equals about 500 lines in Meditech.  We are not paid per line nor do we have an incentive plan, but we have a new HIM Director who would like to institute an incentive plan and the administrator over our department has laid down the law and decreed that all transcriptionists not making minimum in the department will be written up.  Problem is according to Meditech line totals that we have been given, that would be about half the department.

The transcription supervisor has taken our concerns to the new director who told the MT Supervisor to hold off on writing people and has taken home all the line counts from the last month and she is going over them with a fine tooth comb this weekend.

I am not a very trusting soul by nature, so I am doing a little research on my own.  I've been in this business for about 15 years.  I started out in a hospital and have worked for a few services at home and am now back in the hospital setting.  So I know a few things about line count and I consider myself to be pretty well informed on trends and technology in the industry.   I would like to walk into our next department meeting armed with as much knowledge as possible.  So I have come up with some questions that I would like some fellow MTs to answer, give opinions, and maybe even direct me to websites or individuals who could give me a better understanding of Meditech and Cerner.  Here are my questions:

 


  1. Is it possible for an MT to have access to her line count in Meditech or is strictly a management function?  Any MTs that work in Meditech on this board, do you currently have access to your line counts and if so, how do you check them?  Is it an option on the main menu after you log into Meditech?

  2. How is a line defined in Meditech?  (i.e. 65 cpl, with spaces, without spaces)

  3. How is a line defined in Cerner?

  4. What abbreviation Expanders work with both Meditech and Cerner?

  5. Examples of incentive plans (if anyone would like to share that with me that would be great, if not I completely understand).

  6. Measuring productivity by minutes of dictation versus typed lines.


    1. What would be the minimum minutes required for an 8-hour day?

    2. How would one structure an incentive program based on minutes?

I was thinking of presenting the idea that we keep track of productivity using minutes instead of lines since there is such a discrepancy in Meditech.  I also worry that if an incentive plan is put into place and we are still typing blind into Meditech, what's to keep management from shaving off a few lines here and there?


Feel free to email me or post here any responses.  Either is fine.  I really appreciate any input, comments, or just plain old supportive posts would be nice too! 




ER notes

Don't worry.  It has been my experience being a Transcriptionist for a huge hospital that I loved the ER notes the most.  They are really pretty much abbreviated H&P's and are sometimes the most interesting reports of all.  Not nearly as difficult as some surgeries or discharges notes can be.  Simple and brief and sometimes a really good story.


OP NOTES
I just started doing op notes at the hospital I work in and it is hard as there are so many different instruments they use that I have never even heard of. I use a surgical word book and Google a lot. That's about it.
To me, O.R. notes
get really boring.  I prefer discharges  - just my personal opinion.  Plus once I get used to them, I can go really fast. 
Doc notes

I do two internal medicine Docs, SOAP notes only and minor procedures and love it  I also did other specialities, but all that was lost to outsourcing to INDIA!


op notes
Operative notes.  Perhaps as far a leap from clinic work as is possible.  Not something for you to jump into with no experience. 
Not op notes but
This site has brand names of surgical instruments. You can choose by speciality and manufacturer also.

http://ptiresource.50megs.com/about.html
Even for op notes? sm
I can see where being paid this way would have its advantages when doing DS and work types where there is a lot of paper shuffling, looking for values, etc., but I am concerned about op notes where the dictation is speedier.
OP notes

I love doing OP notes. They are so interesting. Anyway there is a website that I use now and then and it is


www.mt911.com it also has samples.com on it and has alot of different samples.


Also a good reference book is The surgical word book by Saunders.


Hope this helps.


OP notes
I only type OPs. I have done it for 8+years and LOVE IT.  Its a niche that is hard for companies to fill, it seems.  I would say it would be a great move on your part.  Good luck!
Op notes
At my current company, op notes are paid at 9 cents a line for over a year experience. At my previous company, op notes were paid the same as any other type of report; cpl was based on difficulty of the account and ranged from 7.5 to 10 cpl, with op notes being paid the same as other basic 4 reports.
OP notes
If you already work for a service, maybe they have OP accounts. I would tell them you would like to learn. Ask if they could assign you a few each day and have them go to QA for feedback.

I would also buy a few surgical reference books. I feel the books are much easier to use than Google because so many instruments, brand names, etc, sound alike.

Good luck. I love my OP accounts.
RE: OP notes
Some people like OPs and some people like DS. I like DS. They talk too fast on OPs. If you can get them down, they say about the same thing. You can put that in your shortcuts and make more money just by popping it in there.
OP notes

Any good sites for OP notes?


thanks Lori


Op notes

Does anybody have any tips on the best places to specialize in op notes?   I need a place where I can do heavy volume ops -- not interested in basic 4 stuff.


Thanks.


 


me too as far as the notes and sm
standard phrases for certain docs go. It was nice when the docs would come in and talk too or even fuss sometimes! haha Most MTs knew how to come back at them and didn't take a whole lot off them and didn't have to. They respected us (at least most of them) for that. I think there are actually docs now that don't even realize there is a "person" behind all of this doing MT. NEver thought I would see this profession get like this taht's for sure.
And probably her notes look like

Op notes do fit in expander (nm)

x
So if you've never done OP notes,
do they figure 3 out of 4 ain't bad????? 
Would like to exchange notes..sm
I'm thinking along these same lines..email me. I have some questions.
Love OP notes, which I could do them always. nm
xxxx
I'm used to op notes, been doing DS lately, hate them. nm
nm
Chart Notes

Was wondering if anyone could help me out.  I need to see some example of different ways to set up chart notes.  If anyone knows of a place on the net i can view these of would send me some blanked out that would be great!!!!!


 


 


Thanks,


Jackie


Lotus Notes
Has anyone used lotus notes to transcribe in?  Any info appreciate.  Please email me if you like. Thanks!
I love ER notes and of course I never get them. sm
My favorite and I still laugh over this, was the patient that came in with a double AA battery in the rectum. Mind you the patient was about 25. Doc snickered all the way through the report and told the patient never to put anything there again.
yeah, I have all that already, that is the notes - sm
I refer to. If I have to I will re-piece it all together based on his info. and my own notations. First have to get the computer operational again, one step at a time.