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Serving Over 20,000 US Medical Transcriptionists

Google "soap note" and you can find it easily.

Posted By: nm on 2008-01-17
In Reply to: SOAP Notes - amylou

XX


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You can probably find some on Google.
x
Just google and you will find several.
nm
Can someone who can access Google find an
:(
Yes. I find it spelled both ways on Google.
NM
Thank you, could not find it in any of my word books or Google
xx
do a google search-were many hits and should find good info--nm
//
If you google "print folder list" you'll find a lot to choose from.
Example: http://no-nonsense-software.com/printfolder/

Google South Beach Diet forum and you'll find a good board there for information. nm
s
Just make a note in your book and go on. Every book I read you can find an error
or 2. Nobody is perfect. Lucky you only paid $60. New it is $80 or more.
Merry Christmas! There is a story named Cat and Mouse Christmas...search Google and you'll find
x
You can do this very easily....sm
I've got the same type of setup that you're looking for. I use the Linksys routers and have a wireless router for the desktop PC that is on the other end of the house and use a notebook wireless card for my laptop. The entire setup took less than 10 minutes and their directions are idiot-proof to follow (trust me, I'm technically challenged and I got it right the first time - woo-hoo!)

Do be sure that you set up a password on your wireless access, otherwise someone could easily hack into your access. The easy directions for this was on their website as well.

Feel free to e-mail me if you have any specific questions and I'll try to help you.
Especially easily happens
because we use expanders. I once had a report sent back because I had expanded ankle pain out instead of abdominal pain (twice in the report!)... I couldn't believe I didn't catch it when proofing. I guess it must have been one of those brain fog days when I have trouble proofing (along with trying to hurry).

Really when you consider all the poor dictation (along with their actual content), how easy it is to transpose letters or hit the wrong key and expand out something totally off the wall in a particular document, trying to hurry as fast as we can while making tons of little decisions along the way ... we do pretty darn good!

Don't beat yourself up. :)
It can EASILY cause that feeling and yes, it is ...
working from home that does that.

It nags on you because it is "never completed", there's always more to do.

You need to get out of the house and do something OUTSIDE and something WITH OTHERS. That is why I volunteer (see my post a few threads below under "Answers").

You have to really keep a tight rein on disciplining yourself to keep a firm wide boundary between your home life and your work life because they are BOTH at home.
oh please, you can get AIDs here just as easily.
x
MDs not so easily impressed.
<MTSO for firing this lady>>

No, no, no, he was probably quite surprised and annoyed to be called by an a subcontractor he doesn't know from Jack, rather than the MTSO he hired to do his work. The MD is the one complaining to the MTSO when she doesn't meet TAT, and she CAN't meet it if the IC she hired doesn't send her work in on time. So what does she do? Offer the work to somebody who is more motivated than you. It's business.
You would be surprised how easily someone....sm
gets "lost in the shuffle."  There are so many people applying for jobs and sending resumes.  I found that the applicants who continued to check with me where much more apt to get positions.  If I really didn't want someone because of their abilities, I would just tell them I had no openings, and they would stop contacting me.  You don't want to bug them to the point of irritation, but you certainly should check.
I can easily see the difference.
I don't think you have a problem here.
You can easily do it without the macros. sm
Add an autocorrect. Now do a search for the .acl file by the date you made your change so you know you have the correct file. You need to make sure you are searching the hidden files and you probably need to change your search view to Details so you can see dates. You can right-click the file and send it to your CD (or however you want to transfer the file).

Do the same thing on the new computer so you can find the correct folder path and paste your file.

Sometimes the MS macros don't work because you probably have some entries that are multi-line with paragraphs.

Yes, I could easily become a recluse. Force myself to go out
dd
It could have easily cost you your life. nt
 
???? She didn't! We can easily see the difference.
nm
Enrichment is done easily in IT, although it can be done in Shorthand sm
This is where you take several days' worth of work for one doctor (if you have your dictionaries divided by doctors) and run the Enrichment option in IT. It looks thru the work and picks out the common phrases and words and automatically adds them to your dictionary. It's really cool! Shorts you didn't know were there suddenly pop up for you all the time. A lot of times it's things it never even clicked to me that the doc says it all the time.

If you want to do this in Shorthand, it's not automatic but can be done. You need to have another piece of software (or a website) and you enter your text in there. It picks out the common phrases and lists them out for you. Then you have to manually go to ShortHand and enter them. Takes quite a bit longer, but still worth it!

I would suggest y'all head over to productivitytalk.com and start absorbing all the knowledge for your particular expander. There is just a ton of knowledge over there, it will blow you away!
and you could have just as easily skipped my posting by that reasoning
Okay, Message Board Police. Next time I decide to express my opinion I'll run it past you for permission first, okay?

Amazing
Yep, google has it goin on... I really like the google earth...
Have you tried Google earth? You can type in any address, street, city, state, country, etc. and it will zoom in and show the area and then you can hit the + button and zoom right in and see the exact house, building, etc. that you are looking for.
Mainly Google; I google the known words in the phrase (sm)
That's my most frequent tactic if I don't find the word in my word books. I'll play with leaving certain words out and adding them in, in various combinations, to try to get a hit that has a word which sounds like my blank. If I get a hit, I'll Google WITH that word, and see what hits I get, and what their source is (i.e.,checking the sources out for reliability). When I say 5 sites or searches, I mean I don't often try more than 5 different combinations without a serious hit. If I get a hit, then I will spend a little more time checking that out before I give up.

If it's a drug name, I use RxList, or more frequently the Drugs.com website. Since they redid RxList, I haven't found one that has quite as good a wildcard search, but Drugs.com works okay most of the time.

If it's a place name (like when they give names of outlying outreach clinics and etc.) I'll use Mapquest and look up the city my hospital is in, then "pan out" and look at the outlying towns.

Hope that's what you're looking for. I do have bookmarks, but I find that even the ones I think I'll visit again, I waste more time doing that than with an intelligent google search. An example is the time I was looking for "banana bag." The only place I managed to find it with a degree of reliability was on a nurses' message board. I've found quite a bit sometimes on the various specialty message boards out there, but I think the quickest way to locate that is through a search engine rather than bookmarking each individual site and trying to figure out which ones to search for a particular term.
Open, easily approachable, and true communication is key.
.
But since you can switch so easily from one to the other, I just use my email on my main computer &
s
Static IP address are not as easily attained as you would imply.
Also, most newcomers to the idea of FTP file transfer are not anywhere near the technical level of experience that you claim to have. My answers are being given to provide a SIMPLE solution for this person.
Static IP addresses are not free, either, so despite what you want to assert, your solution is not FREE.
If one is a nonproduction job, managerial,etc wool can be easily pulled
snap!
Did you just say: You can very easily "add lines by inserting a word here and there"
I recall back in the mid 1990s, I was working with a fellow MT who was on midnight shift in medical records. He was making a huge sum of money and we all thought he was "the Whiz."

Come to find out, he was inserting phrases, embellishing dictated sentences I guess you'd call it, to get more lines per report. He got away with it for a number of years but was kissing up to the supervisor and director, always available to help out, nicest guy in the world - but a thief - who fooled us all.


Radiologist would surely notice eventually if not QA.
Thank you, Google God. My google icon is
x
go to chat room on web site and find out. i'm working but if you find out, let me know.
creepy dude.
I find most of my abbreviations here. Scroll all the way down until you find the abbreviation box.
http://www.mtchat.com/frame.php?frame=message
Thanks for your note. SM
I think this problem must be specific to my particular account. I have tried all the things we were told, clearing, entering new names to try, etc. Thanks again.
Note to MQ: What would be

retired MTs in your workflow room and being TC's.>?


I am so tired of dealing with haughty people who don't have a clue


why I need something or what I do - and on top of them coping an


attitude with me because I get exasperated with their inability


to do their job which is make the work flow.


If MQ had people hired in their work flow areas who had worked inside


the world of transcription and knew where it goes in a hospital,


what to look at on the screens of the machines in the work flow rooms,


etc etc we wouldn't be getting hysterical messages all the time about


not meeting turn around times.


But no!  they want to hire first-time jobbers to be in control of the lives


of people who have been in the business usually upwards of 15 years


in order to even do this MT job at home with no help or assistance -


and then make us put up with them and at the same time try to make a living.


I don't want a doctor operating me who has never been inside a hospital, and I


am sick to death of dealing with people in a transcription company


who has never been inside a hospital and followed a REPORT around.


They need to see WHY A REPORT is done - HOW IT IS DONE


They need to go to dictate stations - they need to go in a medical records


area and look at charts - go inside an OR - and into the ICU


they need to see how the world of medicine is and how it operates.


Only then will they understand TATs, reports, and why things are done as they


are or at least why people want them done a certain way.


Like if I keep getting dictations with LOUD BUZZING - i don't want to keep getting


LOUD BUZZING - I want to let the hospital know there is probably a bad phone


instrument - and if this work flow person sees where dictation is done he will


understand it wouldn't take much to MAKE THE BUZZING STOP - and not get


pissy with me because I'd like to talk to somebody about LOUD BUZZING ON


REPORTS. - It's not rocket science - just need to let somebody know.


I know this isn't a note, but
maybe this will be of some help, I'm still searching for a note.
Breast-Related Medical Terms

GLOSSARY OF MEDICAL TERMS
Areola The pigmented or darker colored area of skin surrounding the nipple of the breast.

Asymmetry A lack of proportion of shape, size and position on opposite sides of the body.

Autoimmune Disease A disease in which the body mounts an "attack," disease response to its own tissues or cell types. Normally, the body's immune mechanism is able to distinguish clearly between what is a normal substance and what is foreign. In autoimmune diseases, this system becomes defective and produces antibodies against normal parts of the body, causing tissue injury. Certain diseases such as rheumatoid arthritis and scleroderma are considered to be autoimmune diseases.

Axillary Pertaining to the armpit area.

Bilateral Pertaining to both the left and right breast.

Biopsy Removal and examination of sample tissue for diagnosis.

Breast Augmentation Enlargement of the breast by surgical implantation of a breast implant or patient's own tissue.
Breast Reconstruction Surgical restoration of natural breast contour and mass following mastectomy, trauma or injury.

Capsular Contracture Tightening of the tissue surrounding a breast implant which results in a firmer breast.

Capsulectomy Surgical removal of the entire capsule surrounding a breast implant.

Capsulotomy Closed Capsulotomy: Compression on the outside of the breast to break the capsule and relieve contracture.

Open Capsulotomy: Surgically cutting or removing part of the capsule through an incision.

Carcinoma Invasive malignant tumor.

Congenita Anomaly Abnormality existing at birth.

Connective Tissue Disease(CTD) A disease or group of diseases affecting connective tissue. The cause of these diseases is unknown. The diseases are grouped together on the basis of clinical signs, symptoms, and laboratory abnormalities.

Deflation/Rupture Refers to loss of saline from a saline-filled breast implant due to a tear or cut in the implant shell or possibly a valve leak.

Displacement Shifting in the original position.

Epidemiological Pertaining to the cause, distribution and control of disease in populations.

Extrusion A breast implant or tissue Expander being pressed out of the body.

Fibrous Tissue Tissue resembling fibers.

Hematoma A swelling or mass of blood (usually clotted) confined to an organ, tissue, or space and caused by a break in a blood vessel.

Immune Response The reaction of the body to substances that are foreign or are interpreted as being foreign.

Inframammary Below the breast.

Inframammary Fold The crease at the base of the breast and the chest wall.

Inframammary Incision A surgical incision at the inframammary fold

In-Patient Surgery Surgery performed in a hospital requiring an overnight stay

Latissimus Dorsi Two triangular muscles running from the spinal column to the shoulder.

Mammography Use of radiography (X-rays) of the breast to detect breast cancer. Recommended as a screening technique for early detection of breast cancer.

Mastectomy Surgical removal of the breast.

Subcutaneous Mastectomy: Removal of breast tissue, preserving the skin and nipple.

Partial Mastectomy: Removal of primary tumor and a wide margin of tissue, may include the overlying skin and the muscle fibrous tissue (fascia) underlying the tumor.

Total (Simple) Mastectomy: Removal of breast tissue and the nipple; sometimes accompanied by armpit (axillary) node dissection.

Modified Radical Mastectomy: Removal of breast tissue, nipple, and fascia of chest (pectoralis) muscle with axillary node dissection.

Mastopexy Plastic surgery to move sagging (ptotic) breasts into a more elevated position.

Necrosis Death of tissue. May be caused by insufficient blood supply, trauma, radiation, chemical agents or infectious disease.

Oncologist A specialist in the branch of medicine dealing with the study and treatment of tumors.

Out-Patient Surgery Surgery performed in a hospital or surgery center not requiring an overnight stay.

Mammaplasty Plastic surgery of the breast.
Mammary Pertaining to the breast.

Palpate/Palpability To feel with the hand.

Pectoralis The major muscle of the chest.

Plastic Surgery Surgery intended to improve, restore, repair, or reconstruct portions of the body following trauma, injury or illness.

Prosthesis An artificial device used to replace or represent a body part.

Ptosis Sagging of the breast usually due to normal aging, pregnancy or weight loss.

Rectus Abdominus Major abdominal (stomach) muscle.

Saline A solution of sodium chloride (salt) and water.

Seroma Localized collection of serum, the watery portion of blood, that resembles a tumor.

Serratus Muscle located beneath the chest's pectoralis major and minor muscles and the rib cage.

Silicone Elastomer A type of silicone that has elastic properties similar to rubber.

Subglandular Placement Placement of the breast implant behind the skin and mammary gland, but on top of the chest (pectoralis) muscle. Also called prepectoral or retromammary placement.

Submuscular Placement Placement of the breast implant under the chest (pectoralis) muscle, or under the pectoralis and serratus muscles. Also called retropectoral or subpectoral placement.

Surgical Incision Cut made in tissue for surgical purposes.

Transaxillary Incision Incision across the long axis of the armpit (axilla).

Umbilical Relating to the navel.

Unilateral Affecting only left or right breast.


Anyway, sorry, on a more serious note...
as regards your problem:  Do you have Ad-Aware and SpyBot and have you run those?  If you have run those and are still not finding anything, you might want to try a trial of this program I just downloaded myself and seems to have gotten rid of this darned WinFix (Virtumond?) pop-up problem I've been having recently that my Ad-Aware and Spybot couldn't seem to take care of.  Dang, I might actually buy this one!  But anyway, you can use it for 2 weeks, I think it is, for free (see link below).
Just a note: There are two MTs that I will not SM

use to this day - 15 years down the road - because they did this. They will never get a recommendation from me and they will never sub for me.


You leave a long trail when you do something like this.


on another note
I know a lot of people believe as you do, but in my family I have seen lots of evidence to contradict this theory.

I don't condemn anyone who overdrinks, but I think we spend too much time in our culture blaming genetics and other people - mostly our parents - for our own poor choices and bad behaviors.

Bottom line is, the alcohol does not force itself into anyone's mouth and neither do the drugs. To me, drugs include not just the street drugs, but the legally obtained prescription drugs that so many people rely on to get them through the day (do not flame me about arthritis meds, etc. taken for legitimate conditions).
P.S. and it's an OP note!
nm
On that same note...
I wonder if any of you report errors you notice in other reports to the QA at your office. I have seen some doozies, but I admit I have been remiss. I just wanted to know what the rest of you do, even if the report is old.
sorry -- BAD day. (no note)
.
NOTE,,,,,,,,,,,,,,,nm
nm
perhaps you could drop your TC a note...sm
just to say hi, and welcome.  She/he has many, many more people to get in touch with than you do, so why not make the first move? I'm not at all trying to be ugly, please don't take it that way, it's just, why not just send a message saying hi, and introducing yourself? Just a thought! Good luck with whatever you choose to do!!!
perhaps you could drop your TC a note...
I guess you mean Transcription Coordinator -- what I called my new supervisor. I hear you, but I really don't see that as my responsiblity. MQ is so chaotic, I always get the impression they'd greatly prefer not to be bothered. I'm kinda way past that point with that. Thanks for the welcome anyhow.
perhaps you could drop your TC a note...
I think you've misunderstood me. I agree completely with your most recent post, i.e. being left alone to do my job. Absolutely. I just don't think a courtesy note from a new supervisor is too much to ask. That's not breathing down my neck; IMO, that's courtesy, i.e. Here I am, I'm your new supervisor, here's how things may or may not change, just wanted to say hi and make proper notation of the fact that a change has taken place. WHATEVER.
perhaps you could drop your TC a note...
Okay, now you're making me mad. You don't know me, and you have no right to lump me into a goup with "(my) fellow nut-case MTs" ...and you have the gall to say "nothing personal"? Freakish behavior? Talk about the pot calling the kettle black! Wow, I came on here looking for some support, and now I'm a freak and a nut case. No thanks! See y'all around!!!
perhaps you could drop your TC a note...
Read your phrase: "your fellow nut-case MTs." It does not say "your fellow MTs, some of whom are nut cases."

Read your phrase: "freakish behavior en masse." It does not say "the freakish behavior of some MTs."

Both of these groupings include me. You are guilty of bad syntax and just plain rudeness. I consider these equally offensive. I most certainly did not fly off of any handle, nor did I (until now) TAKE TO WRITING IN CAPITAL LETTERS TO EXPRESS MY OPPOSITION TO YOUR POINT OF VIEW when a little careful wording would've rendered that unnecessary. I proved you point? You sure proved mine. GOODBYE.
Note for Souzam
Sorry to change the subject, but did you even test for KP? If you have any more questions e-mail me at lilygirl54@adelphia.net.
AN OPEN NOTE TO MTS

1-Do not wonder WHY work is being sent overseas when in screening applications 20 of 25 resumes are full of errors, typos and people applying that do not come NEAR to fitting the job requirements.


2-Do not wonder WHY work is being sent overseas when you are hired to work hours YOU REQUESTED and then you do not even bother to start work, call, email, just nothing. 


3-Do not wonder WHY work is being sent overseas when you are tested and screened only to find out that several "friends of friends" circulated the test around and while you do wonderfully on the test, now in the real situation, you can not figure out the difference between discrete and discreet.


4-Do not wonder WHY you were given less and less work, but take a look at the quality of work you produced...full of blanks, not formatted to specifications in the manual sent, skipped reports.  When Q*A has to redo 90% of your work, it is easier to quietly phase you out than to continue to "train" a supposedly seasoned MT


5-Do not wonder WHY you were taken off an account, but look at the feedback you were given regarding the continued mistakes with spelling (you do not use the spellcheck as too time consuming - your words), continued mistakes with doctors signatures, names, formats, phrases.  Your position is to "pound out lines" and not worry about the quality. 


6-Do not wonder WHY no one will hire you...after all, MTSOs communicate with each other too and the same names just seem to cycle through


7-Do not wonder WHY companies look overseas for workers...because at least THEY want to work.  They are not taking days off at a time with no notice...leaving a company and client in the lurch. 


8-Do not wonder WHY your resume was not answered...you applied before, were tested before and never bothered to answer emails regarding hiring...never bothered to start on your start date...resumes are kept and note made of why someone that seemed very qualified was not hired.


9-Do not wonder WHY you were not hired...remember me?  I am the one that tested you, screened you, then talked to you for quite some time on the phone interviewing you.  Remember me?  I am the one you "sold" yourself to as far as being ethical, good worker, etc., only to find out that you received the hiring package, then contacted the client directly and suddenly, you did not want the job and then I see you are working FOR THEM....


10-Do not wonder WHY you were not hired after taking the test...take a look at the test results and the responses back you made like "that is how I have always done it" and I do not think you are correct because that is not how I was told or trained to do it.


11-Do not wonder WHY you were quietly let go...check your invoices and the inflated lines and/or hours on there?  The system SHOWS the reports you ran, lines you did, but you continue to add report numbers not done by you and lines not done by you.  AND for bonus hours...you continue to add bonuses that were not earned.


12-Do not wonder WHY I cringe when it comes time to hire again..I cringe because of every MT out there that shows NO RESPECT to a potential employer now or down the road by ignoring remails.....receiving a test, but never taking it...getting a test graded and offered position but never responds back....going through entire hiring process with access codes, start dates and times but then NEVER even starts...or the ones that we PAY a computer guy to get set up and they never start working...or we send software and equipment to and then never get it back or have a legal fight to get it back.


There are two sides to ever story, this I know, but as an MTSO the above are simply a FEW of the hundreds of things experienced in trying to hire just ONE good MT....


Thank you so much for such an encouraging note!

I am going through a separation from my husband.  He thinks a sacrifice is giving up going to the local bar when he gets of work, giving up his drunk he has on a daily basis, and just all in all growing up and taking on responsibilities.


 


I have been so down and depressed lately that I have to FORCE myself to work.


 


Thank you for being the angel on my shoulder today!