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When an account specifies no patient information (as in no name, etc.) in report does that mean no f

Posted By: Kat on 2007-01-18
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information in the reports also, such as spouse name and family phone numbers?

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

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. 

If the account specifies that is different. If they don't specify isn't 2 then the norm? nm
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.

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 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. 
i have 1 account that pays by report
and one that pays by the line. it depends on the day on which is better and if you are able to 'definitely' know what your line count is. if you have lots of normals then per report is better, for me anyway
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.
apostrophe's are out in eponyms unless client specifies otherwise.nm
The license for the Home & Student version only specifies
that you can't use any of the applications for commercial purposes such as writing a book and selling it. Other than that, Word and the other apps work like any other Office bundle. The first answer you got is the right one.
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.
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.
What is the difference between an acute care account and a multispecialty account??..nm
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.

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
what is your account and specialty on the account?
no one is watching. tell us all about osi.
Is the patient
patient name
It's surprising your company lets you put the name in the report.  The trend has been to use "the patient" instead of the name.
The patient is...
The patient is a 2-month-old elephant.

The patient is a 2-month-old infant.

Work from India.
The patient will . . .
be maintained on a clear liquid diet. He is specifically instructed that beer does not constitute a clear liquid. (pt in for alcoholic gastritis) Still chuckle every time I think of that one!
Also that few MDs can say a patient is
slurring without stuttering or slurring the word, "slurring."

the patient
The client preference is to type "the pateint"    To be even more exact, my account instructions state:  "NEVER put patient's name in the body of the report, even if it is dictated.  Always put 'the patient.'" 
Usually if it's a no patient name
allowed either. 
yea, but me as a patient...
when i asked to have copies of my medical records, i was APPALLED at the crap that was in them, by this I mean the errors ran rampant throughout, even if it was just a capitalization error, or incomplete sentences (which i consider errors).

I did not like what I saw at all, but would the average person care, if it doesn't change the meaning?

Patient logs
We are required to do a log for each batch of reports that we do.  I will fill the info on the report and then control + end to the log and record the same info.  Says time for me at the end of the whole document.
Patient info?
Where is my post on typing in patient information???????????
It took me 30 minutes to look-up a patient.
All FIVE of the patient's extremities....
Okey, dokey.  This one's American, too.
Yes, and patient demographics.
I'm not going to compare myself to others, though.  I've made a lot of progress, and that's all that counts.  I've only been on this account for three months.  Who's to say what I'll be able to do next year?
My doc would put that patient on protinix --nm
patient names
This is a problem that I am currently struggling with. My accounts are not 'searchable' and some docs don't spell out the patient's names. I have QC'd these many times with a note AND my e-mail address asking QC if I should be sending all these reports to them minus the patient's name, or send it to them GUESSING the spelling, or just spell the names phonetically and NOT QC them. About 15 requests now, and NO REPLY!! Very frustrating!!! Otherwise, the account is really good. I am new, so did not realize that other platforms gave credit for footers, headers, etc. I know on DQS you get a fair line count on just the body of the report. Don't know about the rest.
when I can't figure out the patient name (sm)

I just leave it blank because, like the other post said, I cannot get any feedback on what is protocol, so I make up my own.  I aint gettin' paid enough to fool around trying to figure out what the dumb doc is saying!


Wow, I think I have PMS or something..I don't usually gripe this much!

Patient Names
You'd be surprised how many facilities have the patient's name on the report. Its not that uncommon. Depends on the facility and the company you work for.
No patient transfered to the LSU
I'm in the procedure section where I cannot abbreviate...Help
RE No patient transfered to the LSU
ICU or CCU maybe - Intensive Care Unit, Coronary Care Unit, can't guess what LSU is in relationship to other than what was said above about football.
The patient is a male

The doctor said:   "He denies bloody or cloudy urine, pain with urination and vaginal bleeding."

I crack up laughing and quote this to my husband, stating the patient's gender.

And his response was, "I hope so."
(think about it)  


This is actually between the doctor and patient.
Your job is to transcribe what the doctor wants. He's the one who needs to be compliant by having the paperwork in order to send these copies on. It's not your problem.
Probably something in patient care, maybe CNA. sm
They make about as much as I am making and with benefits on top of that at the hospitals around here.
Tks you all for being so patient. Looks like I'm out to buy WORD. I

computer and I don't see much, and nothing that says "autocorrect" or auto anything. 

Yes, after being jerked around for several months now and starving to death I will feel better to get my feet on solid ground again with a local company that I know will be around and I know what the rules are (wink wink). 

I'm off to find WORD.  ((I don't know how people who have no time with computers at all, get geared up to work for MQ and do all this stuff with no help.  I know a little bit/very little! and I just can't imagine just starting to work on a computer))

How old was your oldest patient? sm
Doesn't matter if it is someone you took care of or someone you typed a report about. I just did a report on a 103-year-old man and once while working as a aide, had a 104-year-old male patient. Cute as a button and sharp as a tack. Also had a 101-year-old lady at the nursing home. 
As MTs, our #1 priority is the patient, just

as it should be for doctors, nurses and health care professionals.  I know how frustrating it can be trying to translate broken English, etc.  I complain about it, too!!  Sometimes I get so angry, because it actually takes money out of my pocket in that I spend so much time trying to "get it right" instead of just using my knowledge and typing skills typing dictation from a clear-speaking doctor with good English.  Sometimes you want to just scream!!!    BUT, again, it is part of our job to provide an accurate  and presentable medical document.  I wish things were different, but it appears that we have to work with what we've got or learn a new profession. 

That is my humble opinion.  

Pain Patient - Where are you??
I have been SO WORRIED about that lady last week who was withdrawining on her own from OxyContin and was gonna go alone to a hotel and float in their pool, supposedly with a load of VALIUM that was recommended to her on this board! Good Lord!! I just pray she is not dead. Seriously. I tried and tried to post, but was banned for some unknown reason. At any rate, if you are out there, please let us know you are OK. Also, PLEASE don't withdraw from these meds on your own - you can easily seize from opiate withdrawal - everyone is different, and no way should you take VALIUM.  NO WAY. I am a huge pain management buff, being in the midst of it myself. Its not safe to do alone - I know - been there done that. The best thing to do is check yourself into one of the 3-day detox programs at any local hospital - no matter who your pain mgmt doctor is. I seriously doubt your doctor wants to keep you addicted, and if you called any authorities and reported that, he'd be in deep trouble. Narcotic scrips are one of the few heavily monitored items today. PLEASE DON'T TAKE VALIUM off scrip. There are outpatient meds like Suboxone - supposed to be a miracle pill. 1 or 2 pills a day, no withdrawal, no urges. Or you can get detoxed under anesthesia in a few hours. Or do the inpatient detox in 3 days with clonidine and possibly Ativan for anxiety. NO VALIUM. And they are set up for giving you the antiseizure meds immediately should you develop seizures, which is common. PLEASE tell me you are OK, and I have given you my email address if you want to write privately. I have been so worried about you. And I 100% totally understand.
Well, the patient does have some control, actually.
The patient can see another doctor without mentioning seeing this doctor, if he/she believes this MD's opinion is worthless. You can hope the best for the patient, but that's about it. Now if you worked in this MD's office as an employee or you were an IC (I am assuming you are doing hospital work and he is just one of the dictators), then you could decide you didn't want to earn your living from him anymore, but if you are in a service/hospital employee situation, then you just groan when you get him, call him ugly names if you work at home, type his reports, and steer your family and friends toward better MDs whenever possible.

I think most patients can recognize a jerk when they meet one.
The patient has never been pregnant
Sounds like she should be a patient there -

First of all, your supervisor(s)/lead(s) or whoever else is overseeing this dept. should be fired.  Sounds like it's out of control - but if they are dumb enough to hire her - what do you expect???

If it is a quotation of the patient, I put it in ==sm
quotation marks. If it is not and just something the doc says, I try to change it without losing the context of the report. patient notes are no place for cuss words. I had a question about it one time and asked my supervisor. she said she wanted to know about it, so I flag it. I even had one doc cussing out the Transcriptionist during the dictation for misspelling a word on a prior document, which I thought was rude, because he has no idea which transcriptionist is getting his dictation. I told my supervisor about that too. He has not done it since.
We are not allowed to keep any patient sm
records on our computers, at all.  They should be stored in the provider's files if they want to keep them for access. 
The patient's status
I got one yesterday that the patient's status currently is deceased.  Wonder if that status is going to change in the future.
Patient list.
I too get a faxed list. However, the physicians use the list first and mark the patients they have dictated on. Then I check off as I transcribe. They do not ask for the list back, but if I notice any that the physician has marked that I did not transcribe, I let them know. In my experience doctors usually swear that they dictated the note and tend to get upset if they have to redictate later. I have worked inhouse in medical records so I also know how frustrating it is when a note is missing. The tendency is usually to blame the Transcriptionist if a note is missing, so it is nice to have that list if something comes up. However, at this office a staff member there goes through and double checks to make sure that the dictation is there. It all makes for a good relationship with the client in my opinion.