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Only typed verbatim twice

Posted By: Once for dictated educated MDs and on 2006-01-16
In Reply to: Seriously, do you *really* type verbatim? sm - SheSha

once for a Russian infectious disease MD. After one week of strict verbatim reports, evidently she got a talking to by the senior partner and her style became acceptable.

The hospital is one of the larget and most respected hospitals in the US. All residents much pass a week-long course dedicated strictly to how to chart, how to document, how to dictate. Each resident must personally sign his/her own name daily on a log in sheet and anyone who misses a day does not get to start with the rest of peers. One day is devoted SOLEY to HOW TO DICTATE and accepting full legal responsibility for the dictation. They have to sign an agreement that the hospital will not provide legal support if their documentation falls short of their standards and the resident has to provide his/her own funding against any lawsuit. If they dictate a reversal of pulse rate/respiratory rate, I could switch them, but I had to send it to QA who attached a note to the dictator covering the MTSO from any repercution.

Best dictators I EVER had!


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Verbatim means that the typed version is the same as the
dictated version, AKA the end result is the same.  You can still use an expander because even if the entire report is not the same, people speak with the same terminology, phrases, and mannerisms day after day.  I love the physical examination portion of my reports because I have every variation of every sentence in my expander.  Sometimes, there will be one or two small differences that I change, but for the most part, it's the same.  Every exam has "His height is" or "Her height is".  With three keystrokes, either hsh or hrh, I get 13 characters and a capitalized first letter.
Verbatim is verbatim, but I defintely to the little things to make the doc look better such as..sm
an eye problem instead of a eye problem.  I definitely wouldn't change too much.  Stick with what they say and only make changes when you absolutely think it is necessary.  I took a test last night and have an interview today and this is what I did.  FYI, I do clinic work.
Verbatim = verbatim......flag it...NM
x
Verbatim for ESL too?
Geez, if that were the case on my account (not MQ), you wouldn't believe the crap I'd be putting out - "59 years old pt, denies of chest pain, comes to ER for short of breath," and I could go on and on.
Verbatim
I still don't understand, for example I have a doc who does about 20 lengthy bypass operations a week.  I have a 4-page "standard", that I just immediately pull up.  He never dictates it the same way twice, I just simply pull up my standard, put ears on, follow along and delete, insert, change and so on as he dictates, and that is as good as verbatim.
Since I am on verbatim also, I use whatever s/he says..
Jim for James etc....however, if the doc is clearly off track, he starts calling Mary by the name of Frank for instance (it has happened) then I flag it.
verbatim
The docs at a big teaching hospital I formerly worked for did not put punctuation marks after the word HOWEVER.  That's the way they wanted it and we were marked down if we added the comma.
verbatim, really?
Of course verbatim means typing EVERY SINGLE word they say, even when it's a side conversation, a snide comment, etc.  One thing I do that may not help them at all but makes me feel that I've at least let them know that I know - I enclose such words in quote marks to set them off from the real words.
Verbatim
As a private IC there was a prominent heart surgeon from Iran whose dictation I "cleaned up" constantly or he would have been the laughing stock of the community. Sometimes you have to "save face" for the client. If I worked for a national and they QA'd me from saving someone from a drastic error, I would immediately "quit." Another ESL went to hospital admin to tell them I was "his friend," I did not change the meaning but there were several instances when I had to make sense of things for him to cover the hospital's reputation. I was taught never to "change the meaning" and to put certain language "in quotes" although as an IC, I would always call the client first and they usually thanked me. When you work for another service, you can't do this, so it makes it very difficult.I guess you have to go with who pays you, but I would never, never type a senseless sentence.Good luck to those who have "bad QA assessments." They should know better.
verbatim
it's stupid and dangerous to type verbatim. Some hospitals stupidly insist on it cuz they believe we can't think for ourselves. They say "We've always done it that way."  Well God forbid you should TRY TO IMPROVE.  they say "well, you don't KNOW what he meant."  My answer to that is "well, YOU may not know, but I do!"  They just don't want to be bothered with having to actually think about it. Any decent trx with many years' experience and worth her salt GENERALLY knows what the doc really means but can't spit out, for one reason or another. I'm married to a doc - I know. But he DOES want us to leave blanks if we DON'T KNOW - better that than making something up, which he does see all the time from Spheris trxs. That's what happens when you hire people with one year of experience and don't monitor them closely, of which Spheris is guilty. And leaving a message for them on ESA doesn't work, cuz the doc won't see it till he goes to sign if off, and by that time, he has no earthly idea what he said. Nor does he care!
IF they got verbatim EXACTLY what they said,
they'd probably be in total shock at how ridiculous they actually sound when they dictate. Don't you just want to give them what they give you sometimes?
Verbatim
The problem is with the client profile. It should not ever have the word "verbatim" in it because the word by definition means "word for word" and we all know all of us from time to time and doctors especially speak garbage and have to be cleaned up. If with followed the client profile and transcribed "verbatim," screams would echo across the country. So I am all for removing that word from all the client profiles unless they truly want reports transcribed verbatim, word for word. We could do that, but it would not be much of a record.
verbatim, no BOS sm
Who are they? I would love to throw the BOS out the window, please e-mail me. Sick of all the new rules which don't amount to a hill of beans anyway at most times.
verbatim
I must be getting old. I'm finding it more and more difficult to "follow directions" as I age regarding this subject. I can't believe these younger physicians don't want us to fix the glaring errors. The real trouble is there's no one who will be the intermediary between the transriber and the doc, maybe, like back in the day. Way too many cooks stirring the broth and complicating what used to be a common-sense and less complicated situation, transcribing, that is.
i do verbatim too, but still BOS has
many points of reference that are helpful. I am one that hated the idea of a BOS, but when i finally succumbed, found there was a lot of useful info in it. Its not a bad idea to have a common reference point.
They may want verbatim, but if they are in
an acute care facility BOS overrides what they want.  JCAHO can give/withhold accreditation based on the medical records and they say follow BOS.  It isn't that is is an issue of style as much as it is a patient safety issue. 
Verbatim
The hospital I work for now is a verbatim account, but we were told to spell out everything in DX, Impression, etc. I spelled out a lab abbrev and it looked so weird, but QA/Trainer told me to spell it out. Very contradictory so if it ever comes back as getting "dinged" for it I am going to tell QA who told me and they better not takes points off my audit.
Just typed in an HP

Under the ROS the heading "Special Senses: Unremarkable"


I once typed for a doc who had
now that was funny!
Maybe that ad was typed by VR... or by an
It irks me no end that our country has shipped off a job to India/Pakistan, etc., that used to be considered important to the medical field, and which fed and housed many of our country's middle-class citizens. So now these foreigners are living the comfy middle-class life, and here I am, trying to rent an apartment and finding that my MT monthly gross pay doesn't qualify me for ANYthing that even distantly resembles a decent middle-class apartment. The only ones I can afford all have "Se habla espanol" in the ads, and of course you know who lives THERE! It's all the non-English-speaking illegals that we've pretty much given carte blanche to come ruin our country, after having done a real number on their own. I hope Uncle Sam enjoys paying for food stamps, welfare, and subsidized housing, 'cause that's where I'm headed unless this profession turns around.
Never typed an ESL??...sm
Now that is strange. As many ESLs as there are. And using the q.d. and h.s. they must have worked somewhere that they didn't use BOS.
--I think she has already typed them.
x
verbatim is hard for me too
It is very hard for me to deliberately type wrong words, phrases, etc. It makes me think someday someone is going to read that document and say "gads where did they get that transcrptionist!" not knowing we have to type it as dictated.
verbatim accounts
I thought the idea was to correct their poor dictation in most circumstances...I'm wondering why any client would prefer it verbatim, for legal reasons?
that is verbatim. QAs are only human too. nm
 
you could fix it if you wanted to or is it verbatim? nm
:
Well, now if it is a verbatim account and
the dictator said, "during this hospital stay" and the MT transcribed "during this hospitalization" -- that is wrong. It all depends on what the client profile outlines.
Seriously, do you *really* type verbatim? sm
I don't. I'm supposed to, but I've told my super that nothing with my initials on it will ever read like "Patient hand swollen." Yep, I take some liberties. I clean things up, I've added in words, taken some out, rearranged words. I think count-wise it comes out even because I'm not padding and I remove words probably about as often as I add them.

If you are on a verbatim account, are you really typing "Obese patient older than says age, no toxic"?
If these dictators actually got verbatim
reports, they would probably have a stroke and need immediate medical attention. It is scary to think that these people dictating take care of us and our families. I certainly hope they are better at treating than they are at dictating.
is this a verbatim account?....nm

How can verbatim=garbage?
We transcribe what professionals dictate.  These people went to college for a long, long time to learn their profession.  Who are we to say verbatim=garbage!!!  Become a physician, then talk that garbage!  Give me a break!  We average $25.00 an hour if we're lucky as transcriptionists, and these physicians are making much, much more than that because they went to school to be a physician and treat patients.  Come on!  Transcription is just that, typing what the doctors say verbatim, maybe correct a little inconsistency here and there (we're all human), but to say the physicians' statements are garbage is wrong, wrong, wrong!  If we were so bright, we wouldn't be typing, we'd be doctors!!!!!!!!!!!  Let's give credit where credit is due!  Bottom line is no doctors-no transcriptionists!  AAMT is just another company out there trying to turn a buck!  They don't know it all and neither do we for goodness sakes!  Do the best job you can because believe me if you are that important in the medical field (as a transcriptionist), you'd make what the doctors are making!!!!!  I'm sure I'll get blasted for this one!!!!  Oh well!
Oy. And I suppose it's verbatim.
So then you have to ask if you are supposed to leave the stoopid stuff in or take it out??


Hate verbatim, also, except
that *if* you get used to it, you really do not have to worry about THEIR errors...

that said, it forces you to NOT care about the quality/accuracy of the work and that sucks for those of us who take price in quality work.

I cannot wait until I can say adios to this work (or at least be able to go to part-time).
Verbatim dictation

The company I work types verbatim as well.  I would not have it any other way.  It is much better than trying to remember 50,000 rules by the BOS!!


Quality and verbatim

Even though you type verbatim does not mean you type all the mistakes the doctor's dictate.  I would NEVER type an error.  When in doubt, it is blanked and sent to QA.


The company I work for is known for their QUALITY and we type VERBATIM on all accounts except stated otherwise in account specifics. 


Verbatim means, according to
the dictionery, word for word exactly as given.  I think that means every single word even the little aside remarks, phone conversations, sort of almost corrections, EVERYTHING!!  I wonder how long they would accept that before changing their minds, or do they really prefer lousy  quality??
simply verbatim
Has anyone worked for this company? Just curious.
No. You said verbatim acct. Maybe that is why
x
Even on a verbatim account,
It sounds as if he was obviously having trouble organizing his thoughts. This is exactly why I no longer work on verbatim accounts. I like being able to use my brain and be trusted enough to make the necessary corrections.
That's why I LOVE MY JOB. VERBATIM!!
No stupid BOS rules to follow.  We type what is dictated unless there is a gross medical error and then we leave a blank and send back to facility!!  We also follow account specifics for each facility.
Is it a verbatim account?
I to am QA and the only way I would take the and out is if it a verbatim account and the doctor did not dictate it. I don't think QA changes things just to make a change. I know I don't.
Not all accounts are verbatim, some,
like mine we are to make phrases into complete sentences, but definitely do not add words just to up the count.
Flag it. Verbatim or not, you do not
knowingly put in wrong info.
Obviously you don't have a verbatim account.
The time when MTs were even permitted to translate jargon and expand abbreviations are behind us.
I have always typed mg/dl and I've been
transcribing early 20 years and have never heard anything about KCl.  I currently work for a service that has a very rigid account and we have had to change several things to avoid confusion, though they have never mentioned this one.   I would think it would be a personal preference.  We use BOS as a rule of thumb, but on Tuesdays and the holiday following the third Saturday of the monh between 8 and 10 we do it this way, and then doctor X wants it done this way, which is totally different from standards, not a coherent dictation but he wants it his way. 
I typed in my sleep once...sm
it was a late shift, about midnight (which is late for me) and I got up to go downstairs, move around, stay awake, came back and found I had typed something about a TV in a box...? So it can be done!
Proofing as you go...as in looking at what you typed?
Doesn't everyone? Or do some MTs watch TV or look up in the air while typing? LOL! That is not proofreading - proofreading is double-checking a finished document.
No, it was a report I typed. Now will you tell me off
a
I typed ENT for 6 years and
charged 14-16 cpl but that was about 4 years ago when you could charge that. I printed everything and picked up, delivered. I eventually had to drop the rate down to 10-12 cpl to keep the docs and then they found someone who would do their work for 8 cpl.

I think you are in the ballpark as well. Good luck.
I have to agree -- not only have I typed ERs for sm

people with cold symptoms, flu, snotty nose, etc., and wondered "why in the heck are they in the ER?," I have also witnessed it firsthand while waiting in the ER with my mom.  She had congestive heart failure and towards the end we made frequent trips to the ER when she ended up unable to breathe and no doctor's office open.  They always ended up admitting her anyway.  But I watched the same thing that the poster below mentioned -- nonemergent cases clogging up the works because they treat the ER like a doctor's office. 


And yes, there are "special circumstances" and such, but that was not the situation you were addressing.  Sorry for the attacks you received.  You just put in writing the thing that many of us have been thinking for quite awhile.


I HEAR ya, but only because you typed it.
I am with you. They really are clueless, aren't they!