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Serving Over 20,000 US Medical Transcriptionists

Not op notes but

Posted By: sm on 2007-07-16
In Reply to: Sample OP NOTE specifically ORIF - Judy

This site has brand names of surgical instruments. You can choose by speciality and manufacturer also.

http://ptiresource.50megs.com/about.html


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And you'll almost never get just Op notes. Probably get mixed acute care - op notes, discharge su
s
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. 
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 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!


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.
cut apart chart notes
Told you I was an old timer.  I print on sticky paper so that they can stick the chart note into the chart one after another on a piece of paper.  It is an 8.5 x 11 label.   I print sometimes up to 3 to 4 patients  on one sheet as I can and  I cut apart the different patient chart notes so the gals in the office don't have to do them and they can be filed right onto the charts.   Just an extra service I provide.   Takes me 5 minutes to do about 20 pages for all my accounts. 
Endo Op notes....sm
I just started a new account for Endo op notes. Does anyone know of any good website that I can use for reference? Thanks.
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.
what are considered ops notes?
I currently type clinic reports but I would like a change. I was considering ops notes. I am not sure what it means when a company indicates Ops notes experience.
Op notes are a blast (well for me they are fun!)
I love doing them personally.  If you can find someone who is willing to let you kinda slowly wade in, it really is something you should try out.  You have to be adept at using all of your resources, i.e. books and internet, and you should have a good grasp on basic anatomy.  You really should have some sort of bonafide surgical word book at your fingertips as well.  If you can give it a shot, I say go for it!  It never hurts to learn something new 
I love doing OP notes

I love doing op notes. They are very difficult though and i do recommend that you go into them slowly if at all possible. I was doing strictly clinic notes when I came to work here, but lost a girl that did the Op notes and we decided to send our clinic notes out to someone else and I started doing OP notes and other types of dictations. They are my fav.


 


I think you will need some op notes experience for sure nm
nm
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.
Maybe you put that you do SOAP notes and HR
nm
What are SOAP notes?
nm
Clinic notes

Mostly clinic notes from my experience:


S - subjective


O - objective


A - assessment


P - plan


 


soap notes

Yes that is correct they are chart or clinical notes.  The dentist that I used to work for liked the charts written up in that fashion.


S- subjective


O- objective


A- assessment


P- plan


SOAP Notes

I may sound dumb, but what is a SOAP note??


What sort of notes are these?

Do you mean that they are written notes or are they on a dictaphone system??  I am just wondering why you would need someone close by?  bj


So do you have the missing notes??
If you have the missing notes then someone is misplacing them and you simply charge them a re-printing fee.    Are you doing digital and delivering back or do you pick up tapes?   If they want more delivery back, charge a delivery fee.  You can make it work if you want to but they will have to pay for the time you are putting into the work.   If you feel someone at the clinic is doing your work, explain that also.   Good luck. 
Missing Notes

I have that problem once in a while and my doc and I got into an argument about it once. I knew he didn't dictate the notes, but he kept telling me he puts a check mark on the notes he does dictate. 


I've been with this doc since 1995 and I have a phone in system, so if he dictates them, they're transcribed. If he doesn't dictate them, then he didn't do them.


Well, for how busy he is, if he put the check mark on the note PRIOR to dictating, then gets called away for a patient or starts to fall asleep while dictating (which he has done already), it could very easily be overlooked. What aggravates me is that he makes me type Re-dictation on any notes he says he did before but didn't.


Also, I have found that since the last secretary left, there aren't as many "missing notes" as before. Hm-m-m-m. That tells me something. I can understand if I put a blank for the patient name (no list to follow and if it's a new patient or can't understand Speedy Gonzalez, then those notes could very well be thrown away if they can't verify the patient.


I don't print the notes or hand deliver them anymore. We use PCAnywhere, and the notes are in one file with the dates of the notes dictated, which I transfer directly to his computer, so they print them out on their end. I have the notes and so do they, so if they are missing a note, all they have to do is check their files to see if that note is there. If not, then he didn't do it.  End of argument.


This has worked out great for me, but for you, well, I'd think twice about keeping a job with that much aggravation. Find another account.


 


P.S. - and also, I have had missing notes too
dictation system by the doctor when they dictate.  So instead of coming to your pool, it ends up somewhere else.  And someone in the hospital ends up getting it and, not being sure what it is (or maybe knowing but welcoming the easy work), they transcribe it.
I've been off after 3 notes.
Better yet, I've also gone straight to client upload with no QA.
Nursing Notes

I have been having an awful time getting straight with my company whether to use parenthesis for (Please see nursing notes.) etc.  I get corrected back and forth whether the word "see" has to be involved or if "per" is enough or even just (Nursing notes.) because it is implied to look there.  (No matter how I do it, eventually someone says it should be done the other way.)


To top it off, now someone else has totally not answered that part of the question but has said it has to be more specific, such as (See nursing notes dated 02/12/2008.)  That, see nursing notes is too vague, so not to used (  ).  I switched to doing it that way, and got corrected again!!


I end up feeling like a pain in the butt because I keep trying to get an answer, but I get so stressed out by constantly being told by a different QA person to do it a different way.


Anyone else with an issue like this?  And, how do you all handle this particular issue? 


re nursing notes and QA
That's really the pits.  My suggestion would be to document all of these ridiculous inconsistencies.  Another idea might be a source such as this board.  While I don't know who you work for, another thing that may be worth your time is to inquire to find out if other MTs are getting this mess as well.  Geez, nothing like feeling like a human yoyo!
nursing notes and QA

When I was told by QA to do it one way and the next QA a different way, I copied the e-mail and sent it to the other QA and the QA manager, and asked them point blank, which way is correct.  So from then on they asked everyone to save their messages from QA to make sure everyone was working on the same page so to speak, and that stopped that, because they were told do it this way.   Because, found out different QA people have been taught one way and the next QA person the other.  They all have to get on the same page, choose one way or the other and not stress anyone out.  Hope this will stop for you.



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.