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Is it common for doc's to change or add more information to their patient's original report af

Posted By: MT on 2009-06-18
In Reply to:

prior?  I am an IC for four doctors, and they are constantly adding or deleting information from their already signed reports.  Is this the norm?  They keep telling me it is because of insurance issues. I was just curious.  Thank you. 




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When an account specifies no patient information (as in no name, etc.) in report does that mean no f
information in the reports also, such as spouse name and family phone numbers?
According to type of report - i.e., common surgeries,
or physical examinations are what I normally save.
If you are careful with putting the correct report in the correct report shell and patient, you will
not have any problems. I only take away this option when someone is careless. There can be NO room for error on this. One mistake can be very serious. Many do it well though, so just double check and you will be fine.

original poster of prayer sentence information
I am the originator of the post on typing a sentence regarding praying with a patient.  I don't care that he did it one way or the other.  My concern was that I did not believe that it should be part of a dictated medical report.  We don't add patient names.  We carefully word sentences so that the patient is not denigrated in the process and patient care not impacted.  This is not relative to patient care, in my opinion.  I have been doing this job a long time and never had anything like that mentioned in a note before now.  Not at hospitals with definite religious affiliations.  Not when typing for a physician and his staff that regularly do it.  So, I asked a question here.  Based on the responses, it will be the last time I do.  Yes, I do "question' everything I haven't typed before by verifying the word, disease, medication, etc. 
Keep copies of your original report
& if you are being blamed for other's mistakes, get your "ammunition" out & go straight to the owner/manager and ask how this can be corrected and that you will not be taking responsibility for someone else's error.  If your owner/manager is a decent person, he/she will have a resonable doubt from now on when someone like QA complains about "your" work.  Always CYA and don't be afraid to speak up.
I always have it in a place in the report where patient's
name isn't given.  Most likely the account is not a local account (it isn't in my case), the patient's name not given, so I don't think there is any harm done.  I wouldn't make an every day practice of it, but patient's privacy hasn't been violated. 
Hmm..patient information, name of facility, etc. on top of page is a header. Stuff on bottom like ph
,
anyone altering/correcting a report is required to attach their initials after the original transcri
:
Anyone who inputs information in a report - whether correction or not - SM
is supposed to put their initials at the end where the original transcripitionist's initials are. 
patient denies change in bowel habitus? shouldn't this be habit? MD says habitus. HELP!

I typed a report on the wrong patient as the doc keyed in the wrong info, SM
He later said the correct patient's name and I SWEAR to this day I made the changes but somehow the report when through without the correct patient and changes made. I still remember that incident.
I was going to say unless you were the original 3 brave souls named on the original suit.
I still had heard lately that no one else, not one person, had been allowed to join in, so you must be in a separate class??
Even 4.5 is too low. doctors do not change - they still hem and haw, change, change stuff along wit
It is just not enough for the work. Speech is great on the wrists but you are not just reading what is typed, you are making a lot of changes. I have a hard time doubling a lot of days with all the changes I have to make. Just my opinion.
Putting patient versus The patient (sm)
When did this "rule" come about? I've been an MT/Editor/medeical records tech/ART for 30 years - Never, ever was I told to put that. You cannot make the sentence be "The patient sent to Radiology" but you can put "Patient sent to Radiology."

Thats just insane.
Don't change. I had to change back to cable. SuddenLink DSL stinks! nm

nm


Change provider vs change to business plan

In your place, I would seriously consider changing providers if there were others available in your area, but I'd ask around about their service quality first.  It may not be any better.  If there are no other providers, then consider changing your service package to a business account rather than residential.  They're usually more expensive, but they also tend to get faster service if there's a problem.


Last summer, I had no electricity for 3 days due to severe storms, but there were some 600,000 in the same boat with me.  We just had to wait it out.  It's a downside of working at home.


You do not need the 1099. You just need to report the income. Report the company/person ...sm
to the IRS for not sending out the 1099. 
I charge the same amount for a "normal" report as for any other report.
You still have to listen to the dictation and change anything that's different.  I had one woman try to pull this on me.  She'd dictate, "Just pull up my normal, but change this, change that, switch that around, move that, add this, delete that, and change the other."  Then she'd only want to pay me what equated to $.03 per line.  She wanted 1:1 on her dictation to transcription ratios.  I told her to take her cheap account down the road because I'm worth more than that.
Common phrases. LOTS of common phrases, just like ops. SM

pser = the patient was seen in the emergency room


wwd= the wound was dressed


Just two tiny examples. People need to learn to use their Expander programs. I'd be making like $10 per hour without mine. I also work in a job where I do the work type I do best. That's very important. I would imagine (don't know for sure) that H&Ps and DSs have the most lines (I work on a gross line count) but you have to think more, look up more, and type more to get those lines.


I have everything magicked in there. That's the way I like it, that's the only way I will work.


 


change attitude, change life
The first thing you need to change is that defeatist attitude! I know that's hard at times like this, but that's when you need to most.
I won't go into detail, but my financial situation is also at an all-time low, we couldn't even exchange gifts., daughter in hospital twice, & no med insurance)..but then I heard about how much worse things were for others around me this season. Now I'm thankful instead!
Oh, a report just came in. A report actually just slid in, can you believe it. Hip Hip Hooray. I

had better get that sucker typed before it gets out of ONE MINUTE TAT.


Get out while you can. Things will *never* change unless you change them. (nt)

You have a lot in common with him then
for what's making you so angry about your own poor life choices.
We have something in common
I also had a hysterectomy at 28, but my ovaries were gone at 27. It was hell for the first 6 weeks but I went on the hormone therapy...then came the first warnings  about taking them, so I stopped them.  I still have night sweats once in a while, but I can live with it. Now that I'm in my late 50s, seems my body wants to do it all over again. I'm getting hot flashes and all the other goodies that come with the change. Hey! What's going on here???
common among

I mean, 18 YO girls having breast implants, nose jobs...come on, that's for looks and nothing more. But hey, if you can afford it, don't mind pain, and it makes you feel better about yourself, I say go for it...I'd love to have a boob lift... can they do that?


Not only is it not common.
x
it is very common that many MDs.....NM
 
Yes, very common that PAs are some of the
most horrible dictators. I also find they routinely murder drugs and dosages, diagnoses, etc. Really cringe when I get PA dictations, and, though I am of the same gender, usually the awful ones are women, and really do come across with an attitude - at least via audio!
Yep, it can be and is quite common!
I did my first year of transcription on a laptop with external keyboard and mouse.
Can be very common
I've been struggling to find the right fit for a very long time. I try not to put all eggs in one basket because even good MTSOs can lose their accounts - on the other hand finding two or more accounts to work with concurrently is a huge pain -While payment on time is paramount for me too (I have no parents to borrow from :( but so are: a decent platform, fair and competent management, and consistent work flow. You are lucky if you get 2 out of 4. But many will post a different experience (4 out of 4) so you must take all this with a large grain of salt.

You might want to consider supplementing a job as a teacher with a part-time opportunity as an MT - the best of both worlds. Of course, you could offer the MTSO you currently have the opportunity to remedy the paycheck problem before losing you (get your back up set up first though... :)


common

I applied at a hospital for a office job. The position had already been filled. They called me back and asked if I was interested in working in the kitchen washing dishes. Of course this was not my first choice as far as jobs go, but I really needed the job. I took it part time. The day after that I was offered a part time office job at an insurance company. I took that one too. The insurance company was wonderful, and I was able to work the two jobs around each other. In a few months a temp office job opened up at the hospital, because I was on the inside, I was one of the first people to know of the job opening. Hospitals usually hire from the inside first. If they do not fill the job, they advertise it to the public. I do not think that you were being insulted in any way. I guess how you look at it mostly depends on how bad you need a job. When you have to have one, any job looks good. Sometimes we are lucky enough to be in a position to be picky.


It's more common
The only thing I would warn about is that the part-time job especially be as hassle-free as possible. In other words, a long turn around time, supervisor leaves you alone, easy to make lines, fewer ESLs, etc. Otherwise, trust me, you'll dread it. On the bright side, if you're spending a few hours a day watching TV and would rather spend that time earning money, it's a lot less stress when you don't have to pinch every penny and tell your kids "I can't afford it".
8 cpl common at MQ
I've been with MQ a total of five years with a 99.7% QA consistently. I started at 8 cpl and I'm leaving at 8 cpl.
It's very common now
When each hospital had their own radiologist, they were read immediately. But to save money, they now contract outside services and send the films electronically and in most hospitals, none are read over the weekend at all.  What's shocking to me is most don't even have staff to do a CT or MRI on the weekend or evenings either and that floors me because we all know patients come in who need one or the other all the time.  I went in on a Friday to have a CT done and they told me it wouldn't be ready until Tuesday.  It's all money money money.
so much in common, Andromeda
Besides our love of animals.  I raised my 3 without ever one penny from my now dead ex.  In 1977, (the laws were very different then), he had them for a few months in the summer, and he went to court in Florida, where he lived, claimed that I abandoned them, and got legal custody (which I already had in my own state).  He refused to return them, and with God's help, and something that would have appeared like an episode of Starsky and Hutch, I "kidnapped" them  back because there was nothing I could do legally.  Thank goodness the laws have changed since.   Yes, he had the pool, the motorcycles, the money, the boat, etc.etc. and tried to turn mine against me -- but it didn't work.
Thanks, of course I used common sense...sm

before I posted and waited until not only after the press release but after the details came out. We were carefully briefed early on on the details of what was and wasn't okay.


My daughter is going out of her skin waiting to hear.  She loves history and current events at school, particularly the mock elections, etc.  I just think it is a wonderful opportunity to give her this early in life. I hope it makes a huge impression if she gets to go as far as the importance of exercising her right to vote, etc.


One common mis-think that I see is that people think SM

they have to have a whole canned report to up their productivity. How many times do you hear choledochocystotomy and have to think about the spelling? How many times do you have to remember that doc spells his name Brian instead of Bryan? How many times - in op notes - do you hear "the patient was taken to the operating room"?


My expanded stuff is 99% common phrases and hardly any canned reports. My production is huge. Of course, like the poster below, I've been working on my Expander vocabulary for many years and it's just second nature to me.


Those are common. See your OB?GYN or neurologist
There are a lot of medications out that help that type of headache, and my neurologist's office (Dr. Scott Ferer and Dr. Philip O'Carroll in Newport Beach, CA) is doing a trial for those types of headaches too. I had those when I was younger. When I got pregnant with my son, they mostly disappeared. Have you seen a neurologist? They can do hormonal manipulation or other methods. Good luck!
I think this is common sense to the
I believe what she is saying is how to get relief NOW, since perhaps she does not have the funds to pay them?  She cannot very well take a time machine back one year and save up the money now can she? 
Yes, this is common in the MT world.
and see what they say. Don't be shy about it, that is one way of finding out what you may be doing incorrectly, or if your stuff got shuffled to the bottom, or whatever. I wish you the best of luck.
Because it's such common knowledge.
But by all means, give them your money and prove it again if you like! I was just trying to help you.
Lots in common
The post office!!! My husband works there. What a nightmare. It is not uncommon that people leave working there. My sympathies are with you and glad you are doing well now. I went through the same thing. They cut incentive on me at a hospital where I worked when I was a single mom. They told us if we could find more money to leave, so taking the challenge I did and went to the other hospital in the area. Big mistake. When I kind of crawled back to the director of trans who also used to be my friend and little boy's pal, she had no openings (although there were ads for openings). I had been there for more than 7 years too. This year I applied again. Immediately got a "resume will be kept on file for 3 months" letter. Well, that wsa that. It has been 5 years since then and finally I found a great company to work for and believe me, I will never look at grass greener on the other side again. Takes too much work to keep trying out new places and too many heart breaks. But, as they say, "all things work out for the best" and we must in the end believe that one hundred percent. Good luck to you!
Seems like common sense
The negative effects on our health really does seem like common sense.  I love the peace and quiet of working nights, and in the days when I used to work graveyard shift outside of my home, I loved going to the grocery store and running other errands early in the morning when places were was less crowded.  But, I have to admit that working nights kind of leaves me with less than an energetic, healthy feeling.  Through trial and error, the best compromise that I've found for me is to make sure that I sleep at the same time every day, whether or not I am off work for that day, and make sure that I get 5 hours or more of sleep during the dark hours.  I've found that the rhythm of this plan has made all the difference, which is no surprise.  This, of course, is easiest to do in the wintertime.
Is this not common sense?

I think maybe my first month or so of doing MT I would actually try to look up stuff as I came to it.  It doesn't take long to figure out that is the WORST way to do it.


 


 


 


Why not? Just common sense.
x
this is common practice ....
in hospitals.  What our hospital HR told me was that they save all the applications until they have an opening, they then will advertise that opening in-house and if none of their employees apply they will take out the applications.  So, it's quite a long process and really the luck of the draw.  Since hospitals cannot be without the necessary staff even for short time, they stock pile applications ahead of the need.  So often they will advertise and in reality there is not an opening.  Hope this helps.  btw, I'm 64 and just got hired by a wonderful and company working at home.
This is common sense...
He means exactly what EMR means electronic medical record.  Why is this so difficult to understand?  There are many benefits to medical records being electronic.  Research it and you will find out for yourself. 
Again, common sense....

It is not already implemented at many facilities, yet at others it is; thus, the desire to implement it universally.  Below is an excerpt from Wiki regarding EMR.  This should clear things up for you.  Also, spend a few moments reading the second paragraph.  It clearly explains that EMR is an electronic medical record, and the means of achieving that final electronic state are many, some of which include templates, VR and traditional transcription.  So, tell me again, EMR automatically means a point-and-click system?


As of 2006[update], adoption of EMRs and other health information technology, such as computer physician order entry (CPOE), has been minimal in the United States, in spite of studies showing revenue gains after implementation.[2] Fewer than 10% of American hospitals have implemented health information technology,[3] while a mere 16% of primary care physicians use EHRs.[4] The vast majority of healthcare transactions in the United States still take place on paper, a system that has remained unchanged since the 1950s. The healthcare industry spends only 2% of gross revenues on information technology, which is meager compared to other information intensive industries such as finance, which spend upwards of 10%


Pricing for EMR systems is highly dependent on each practice's unique needs. Because every medical practice has distinct requirements, systems usually need to be custom tailored. This is due to the majority of EMR systems being based on templates that are initially general in scope. In many cases, these templates can then be customized in co-operation with the vendor/developer to better fit data entry based on a medical specialty, environment or other specified needs. There are also EMR systems available that do not use templates for data entry and therefore can be easily personalized by each individual user. Alternative data entry methods include concept processing, voice recognition, and transcription.


DO NOT WRITE IT OFF! Writing it off is too common.
Companies who do not pay are becoming more common now and believe it or not, some of these companies are well known to the MTs and many are too afraid to say anything. Follow through. I would certify a letter to the company with a return receipt and give them 5 days to get it to you and if it is not there by then, pursue small claims court being that I do not believe the labor board would be involved in this. Go to small claims court, pay the fee and have them served.
That takes common sense - LOL - nm
nm
lack common sense, one's I have met..nm