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Thanks to both of you...verbatim account. Has to be as dictated unless in diagnosis.

Posted By: I'll QA nm on 2005-09-12
In Reply to: That would be atrial fibrillation. - no slang or abbrevs here

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verbatim means exactly as dictated (sm)
and you said yourself that you were told the account is verbatim and that includes not spelling out abbreviations if dictated.

If you ignored those instructions and spelled them out anyway, then you weren't following the account instructions.

The name issue is definitely something that should be straightened out with QA if your instructions specifically tell you to never type the patient's name in the text regardless of the account's verbatim status.

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.
is this a verbatim account?....nm

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.
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.
Obviously you don't have a verbatim account.
The time when MTs were even permitted to translate jargon and expand abbreviations are behind us.
Hey, I forgot to add... I was on verbatim account

The poster below who said she shouts it back at the screen gave me a big laugh..Its seems funny.. if we say it, its okay, but don't let a doctor!  I think, "How dare her!" But, I did get a laugh out of it, even though I don't like that word!

The account I do VR on is verbatim so can't fix sentences. nm
The problem is if the account is true verbatim...

I only have one doctor on one account who insists her dictation be transcribed verbatim.  She makes TONS of boo-boos, but I type 'em.  The trouble there is, doctors like that regularly say really wrong and stupid things, we transcribe verbatim, and they say we transcribed it incorrectly. 

I honestly believe some doctors are just so arrogant they can't EVER admit to making a mistake.  I am grateful to have docs who actually thank me for catching their errors.  Unfortunately they aren't all so gracious. 

Sometimes you just can't win. 

Also some companies are caught up in the "no blanks" or "everything must be transcribed" - even if it is totally unintelligible gibberish.  So, reports are sent with GUESSES (by QA) with OUR names (initials) on them.  Or QA changes something (that we transcribed correctly) and again our initials are on it.  Chaps my buns.     Now, QA people (and I QA a bit myself, don't get all uppity.  Not ALL QA is like that. 

If it is a verbatim account, I'd vote yes ... although with quotes around it. sm

Do you have a supervisor/liaison/QA person to ask? 


I agree ... not really professional.  Of course, I still cringe when I have to type "belly" instead of stomach.  

I guess that depends if it is a verbatim account...
I think even so I would type feces....
I should have added to type it as "corneals" if verbatim account.
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
I am so sorry for your diagnosis...
I am reading your post with tears in my eyes. That so hit home with me. I don't want to have my kids growing up thinking our house is "normal" as messy as it is. God bless you and I will pray for you. I'm going to make some changes in my life today.
LOL!!! How about this diagnosis... sm

 And I quote - "History of injury of the poisoning at specified place."  I always have to correct this guy's grammar and tense, but what the heck do you do with something like this?!  I typed it as is and sent it on! 

Yes, I did go to the ER and my diagnosis was:

Complicated migraine.  And I am all better now.


Can I get some opinions before I make an appt with a doctor?  Have been having mild fleeting pains in my llq, probably about a week and a half, sometimes midabdomen, the last couple days it has slowly moved upward, now kind of in my chest but still just a mild dull ache - possibly pulled a muscle?  Don't think it is anything serious but is getting more prominent, any ideas?  Thanks.
So sorry about your diagnosis. sm
Why do you think she spread it around?  Concentrate on your diagnosis, treatment, and healing.
So sorry for your diagnosis..sm
you must be beside yourself. My sympathies!

as for the coworker, I can only comment that you had asked her to let you know, which she did. Perhaps she left off the part about the breast cancer because she did not want to be the one to tell you or let you know that. She wanted your doctor to do that. I really don't think she was doing anything wrong...other than maybe every body knows now. you know how that goes.

secondly, and I have said this before, transcription has HIPAA laws, which are a good thing, but because of a situation just like this one, I truly believe that if a Transcriptionist happens to know the patient involved, she should be able to respectfully decline to do that person's transcription. Just as in choosing a jury for a trial...if the prospective juror knows the person on trial, he should not have to be placed on that case. It would save an awful lot of this type of thing from happening, and everybody being *all up in your business*. Personally, if I received a dictation from someone I knew, I would not even want to do it. What is in those files is none of my business.

that is just my thought though.

I wish you all the best on your recovery. May the Lord hold your hand through it all!
Recent diagnosis of MS

Hang in there!  You can overcome a chronic illness and empower yourself.  It ain't easy, but doable.  Been that way for 12 years now.

Just make sure you file the disability with a disability attorney. SS is very well known for denying claims usually twice, then court before they grant it.  This waste many many months and tires us that are already tired, out.  You need all your energy to fight the disease, not for your rights to supplemental income you've paid for all these years. 

Your children will also receive dependent benefits until they reach 18, so again, get an experienced dis. atty.  Hang in there

Also, see what diagnosis code
they used to bill.  Might have been billed as a screening and that's sometimes a no-no as far as getting things paid.  Obviously, you can't lie, but see if she had any symptoms at all that might justify the test.  
sorry for your diagnosis..congratulate you on..sm
your wanting to raise your boys to be good housekeepers. I wish my husband's mother had taught him so many things..just simple little things about the house..like closing cabinet doors. No, truly I understand your thinking and even though I have not been diagnosed with cancer, I think about all the crap I've got stuck out in the shed that I need to get rid of so nobody else has to come along and get rid of all that crap for me. It's a lot to deal with for people who are grieving anyway.
Good luck and just said a prayer for you.
ADHD diagnosis
When our son was having trouble in school, we brought him to an expert in the field of ADHD, and after hours of testing he made the diagnosis, and, then after that got an IEP at the school. Every state is different in their different programs, but they all have to provide help for children with special needs. Our son was at a college at another state, they had his IEP and went there for two years, came back home and is at another local college and they told him he never should have had a full load of classes and he is given extra time for testing, etc. The school system should have a special needs department, like they do here in my state and you can contact them about extra help for autism, learning disabilities, etc. It makes a big difference in getting the kids all the help they need to succeed and not fail in any of the schools. Also, I believe the Americans with Disabilities web site can help also.
Very sorry to hear of your diagnosis...sm..

Like the other poster said, think positive and go forward from here with what you need to do. 

1.  You asked her to let you know if she typed the report so she did so that's not a violation.  It could be a violation if it wasn't emailed through an encrypted email program but I wouldn't make a stink out of that.

2.  She should know the rules and should know it's a major violation to blab to the department so if she has any brains in her head, she'll keep her piehole closed.  I wouldn't worry about it right now or jump to conclusions, but if you do later hear that others in the department know, I would report your suspicions to her supervisor. 

Are there any steps you can take at this point to keep it under lock and key so no one else finds can read your report in that department?

Beyond that, I wouldn't worry about it and would focus on licking this temporary setback.  I wouldn't worry about what's going through her head and why she isn't contacting you anymore.  She sounds flakey.  Focus on you and your family.

My sympathy as well on your diagnosis

But as a radiology MT you know that the treatment for breast cancer has advanced considerably and many women go on to live long, healthy lives after breast cancer treatment. So focus on the positive for the now.

As far as your coworker, I understand the desire to know the results of your tests, but yes, she should have told you to ask your doctor for the results instead of sending them to you.  Then, if she gave the results to anyone else, the HIPAA violation would be entirely on her part.  I don't know if you have spoken to her since she sent you the report, but it is possible that she was either caught sending the email or she talked to someone about it and was reprimanded for the HIPAA violation, therefore she is now afraid to talk to you at all because she does not want to risk getting fired. (Just one possible scenario.)

Your best course of action is just not to worry about the opinion of your coworkers. You have a job to do, and that is to concentrate on getting well.  Don't let this distract you.  Focus on what is important, and "don't sweat the small stuff".

Good luck!

Sorry to hear of your diagnosis
Unfortunately this happens when you have your tests done at the same facility where you are a patient.  I am also a product of feeling like "every knows".  It is not fair to you, but I feel in hindsight now I would never choose to go where I worked to have testing done unless I didn't mind that the people I worked with know of my personal health information.  It is a common thing in hospitals and physicians' offices for people to snoop and want to know your business and unfortunately, this isn't always a positive thing.  If you need other tests I would suggest trying another institution and also mention this to the physicians who care for you, but they may say the same thing - that you should NOT have asked a former coworker to let you know of your results.  Only the physicians have a right to that information and the right to relay that to you.  I fortunately did not have breast cancer, but my incident stemmed from having a mammogram.  My boss posed as a friend in the mammogram department the day I had the lumpectomy.  Yeah right, some "friend".  She was just being nosey and wanting to know when I would be returning to work because the typing was getting backed up.  Again in hindsight, I will never step foot in that hospital again for anything in regards to my health.  I go to a different hospital/radiology department from now on.    Good luck with your health and best wishes to a resolution to your anxiety.
proper diagnosis!!! for my exhusband too...LOL...sm
but it isn't really funny and I'm not really laughing.....it was him or my sanity, as I posted below, and my sanity won out but you have put the proper diagnosis on it because I've been saying for 20 years, he was/is a passive aggressive.....always pointing the finger, placing blame and never looking inside himself as maybe it's him who is/was the problem......(also a triple virgo male *LOL* sun, moon, rising-ascendant). 
Spelling out abbreviations in the diagnosis
when told specifically not to is not following instructions.
We do use dx for diagnosis, and all the short cuts expanders
I am on XANAX. I did not think my clinical diagnosis would be on report.
When given this diagnosis, the first thing you want to know is how far it has spread. It can mean life or death. My doctor was OOT for two more days and I was panicking. I needed to know if it was abnormal so I could begin thinking of what the future held. I am not thinking RATIONALLY!!!!!
Last week I've been diagnosis with Multiple sclerosis and I did sm
go to file my disability and found out what I would get paid if approve, I am working 7  days a week, 24 hours a day off and on.  My husband is deceased and I have two kids to raise and one must do what they have to do.
Diagnosis of perimenopause versus adrenal fatigue? I'm getting very confused on where to turn
To me, my symptoms coincide exactly what to me seems to be perimenopause, but also seem to be some adrenal fatigue as well. Wouldn't adrenal fatigue be a natural result of the perimenopause hormonal fluctations, i.e., very lethargic and listless, insomnia, mood swings, energy swings, fuzzy brain? I'm getting conflicting advice and opinions and just don't know where to turn anymore. I just want this fixed, and didn't think it should be that hard. I went to this GYN my sister referred, but he seemed to me to be rather clueless and had me do some antithyroid antibody tests and put me on fish oil and folic acid! No hormone testing whatsoever. Then, I talked to a pharmacist locally who also deals with women on this same issue (my sister too), who has a Ph.D and consults with the MD. I took her test and she diagnosed me with severe adrenal fatigue, but again, I think this is probably just a result of the hormones messing up. Any advice? I don't want to do a lot of unnecessary testing that insurance doesn't cover, such as the saliva test. I'd appreciate any advice. I'm thinking to just go maybe just go my my PCP and get on an antidepressant or something.
What is the difference between an acute care account and a multispecialty account??..nm
I've never had a problem switching from account to account.
The problem I had was being switched too soon. If I don't get one account spec solidly in my memory with QA feedback on mistakes before starting another, I get confused. The other problem I had with former jobs was inconsistent QA. One person tells you one thing, another person tells you another.

Lately, I don't have a problem with it. Right now, my binder has 8 account specs (some I've never had to use) and I'm picking up a new weekend job for a while. The terminology and report formats stay basically the same. It's just all those little preferences. LOL
and think, the Dr. may have dictated that
At least you ARE concerned about it. Many wouldn't be. Hang in there!
Has she ever actually dictated a sm
report in the format that she is required to do.  I do forms for a cardiologist in this manner, but when I first started working for him, he actually dictated the letters.  I think all physicians need to include certain things for a new patient, and then can do follow-up letters without including past medical history, allergies, etc.  I wonder if she has any colleagues that would be willing to share samples of their reports, but that specialize in the same field.
ROFL at what this MD just dictated...sm
NEUROLOGIC:  He does have diminished memory.  I did start him on Aricept for this last year, but he has forgotten to take it. 
They pay per minute dictated. Sux.
Especially when they assign the work. It's not fun when all your work is less than 1 minute, two line reports, ESL docs, etc.
dictated, not read
I'd take it as a compliment.
If the docs dictated like that, they would never get anything done, lol
H&Ps dictated by a very thorough dictator. nm

Doesn't have to be dictated...but he does
Exams Dictated But Not Done
I transcribe for a local multispecialty clinic and have seen many of my own reports. It just gripes my butt when the doctor dictates a standard physical exam and I know for a fact that he/she hasn't even touched me. Did not check my heart, lungs, abdomen, neuro, extremities, etc. The only things that are legit are the vital signs. It's like if I come in for a sore throat he looks at my throat but nothing else. My fibromyalgia clinic NP only talks to me - no exam at all - yet she dictates an exam, review of systems (that we didn't even talk about). She will say conjunctivae and lids are clear; PERLA, etc., and she hasn't even gotten within 6 feet of my eyes. This just doesn't seem right. And when you have labs or other tests, they NEVER call you back with the results. My PCP never suggests any preventive testing - I have to ask for it myself. I know they're not all like that but my eyes are opened much wider than they used to be. It's all about getting it done in under 15 minutes and on to the patient in the next room. 
I always leave these as dictated.

Let's say you're Asian and have a doc who seems to possibily have a bit of an ''attitude'' about your ethnicity.  In perusing your own medical records, you see that this doc uses the term Oriental instead of Asian.  There's some confirmation that your suspicions were correct, allowing you to make a more informed decision about your medical care and who you want providing it.  Especially true with the word Negro, IMO, which I haven't heard in quite some time but have actually had dictated and left as is, even if I had the leeway to change it.

IOW, I think it's a patient's right to know if a doc is using words like that, so I don't change them.

Doctor who dictated during the PE sm
I had a doc I used to do who treated a lot of brain injuries and strokes. He always dictated during the interview and PE. He would say, in front of the patient...the pt is completely obtunded...the pt is befuddled...the pt is extremely obese, just enormous...the pt's mom is once again out of touch with the pt's needs...and so it went.

The noise was sometimes out of hand, he was a grumbling gravely dictator and that IS all part of the job. It is the thought of being his patient and having him be so brutally honest, well it smacked of unprofessional behavior.

I had a podiatrist who was "too busy" to dictate the day of service, so he would dictate on Sundays. One weekend, he dictated 8 reports...from the bathroom...in the span of about 20 minutes. I got to hear the toilet flush no fewer than 6 times in 5 dictated reports. He kept pausing to concentrate and it wasn't on the report he was dictating!

If the noise is too bad, it gets a blank. I don't care what they say and I don't care where they are when the dictate, but please don't make me know that you have the crap$ while you are on the phone with me. Plainly, I don't want to know.
I would type it as dictated. nm
type as dictated

The word lesbian, unless used in a derrogatory manner, is simply stating the patient's sexual orientation, which could be quite relevant in a psych report.  It's the same as describing a patient as a heterosexual female.  Not intended to "label" someone, simply stating a fact.  I see no problem with typing it as dictated. 

I transcribe just what is dictated.
I do think, if the doctor dictated this
you should put it in the report.
transcribe as dictated...(sm)
Transcribe as dictated: "Patent shotty veins." This is perfectly acceptable as is and does not require rewording.