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Serving Over 20,000 US Medical Transcriptionists

electronic medical record nm

Posted By: Bonnie on 2006-03-14
In Reply to: Sorry for the stupid - New to this

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EMR (electronic medical record) and voice

Yes, they are pushing to make medical records electronic, instead of a paper chart.  That doesn't affect MTs.  We still transcribe reports and instead of the reports being printed and filed in a paper chart, they are part of the electronic record and can be accessed at any computer in the hospital , for instance.  The doctor can sit at the nursing station and pull up all the dictated reports, the lab, radiology reports, etc.


 


Voice recognition, of course, is something different.  There is no one saying that VR has to be used by 2012.  That's simply an alternate way of getting the dictation onto the EMR.


The electronic medical record has replaced MTs at my job..it's all over!

My job has been scanning all the medical records over to electronic medium and the doctors are now taking laptops in the exam room with them and typing in all the info, so basically, my job will be obselete once this transition is over. 


Our boss has been doing a comparison of the clinics who now have the electronic medical record--those docs went from dictating thousands of lines in a weekly period to less than 50!!!  Of course this is a tremendous difference and it's "lights out" for us MTs.  We've got about a good year before it's all done.


Have any of you been affected by this new technology?


P.S.  I didn't care so much anyhow...I hate this industry and this job, so I've been looking for other employment anyhow. 


 


 


Have MTSO's or IC's all become electronic medical record suppliers as well as transcription pr

I've been an IC for over thirty years and the medical offices are now asking me if they can search for old records?  What, they don't keep their own records anymore?  Do all MT companies now offer searchable databases on their company servers for the physician's staff or do they install databases on the physician's computers for this sort of thing?  I've been asked to provide this and I'm thinking "wow, can't the office staff open word and find the appropriate folder and file?"  Is this now a standard item offered by MTSO's?   What happened to medical office management software?  Are transcription companies now becoming electronic medical records suppliers?  If so, please let me know.....If so I've become a dinosaur!



It's probably an electronic health record.
They probably got an electronic health record where it is basically a point and click system that creates a progress note, does the coding, etc. I think this is going to hurt transcription greatly.
He did not start the electronic record, really
Why beat a dead horse? I have been on electronic records for years now, before him. I think you are a hater and any and everything you can find to say about him you will. This is NOT NEW with electronic records. Find something else to gripe about, ok?
Medical Transcription In The Era Of Electronic Medical Records
EMR has revolutionized the healthcare industry in recent times. Many experts felt that EMR & Voice Recognition would totally replace Medical Transcription - however; the industry soon realized that transcription has certain advantages over point & click charting and many physicians preferred to dictate notes rather than document the data at the point of care themselves.
if it was in my medical record?

It would depend upon whether or not it could have a negative impact upon my medical care. If the doctor dictated something like, "The patient has diabetes" (when I don't), yeah, I would ask them to correct the record. But for something like what was stated originally ... heck no. Let it stay.

But that's me ... I don't have OCD and I'm not anal retentive about this business like others. Never have been and never will be.

I still think you need to lighten up. There's a lot more to worry about in life than something like that.


Electronic Medical Records?? What do you think? SM

Ok, so I went to my doctor's office today and noticed that they just installed a computer station for all doctors in the clinic to start doing their own records while they are visiting you!  What do you guys think?? Is this the end of our profession or is our profession going turn it to something else..like editing those reports that the doctors have to type.


Is this a real problem or will it be many years from now before it effects us?  Let me know your thoughts.


Thanks....


Electronic Medical Records
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electronic medical records
Does anyone have info regarding EMR rules for doctors.   I was told by a physician today that by 2010 that all doctors were supposed to be EMR.  What will this do to our transcription jobs?  Any info appreciated.
electronic medical records

Here's the scoop on EMR.... right now not all facilities have everything electronic, but they are working on getting electronic on all records, however, there will still be paperbased files. What MTs need to do is to become familiar in the electronic field and not just limit their skills to transcription, because, lets face it today NO ONE stays at one job for years and years, no matter what the specialty, you need to keep educating yourself, better your skills, and move on to bigger and BETTER things!!! It will eventually change, after all, even AMTA changed their name:)


Electronic medical records. nm
nm
Electronic medical spellchecker

Can anyone tell me the best electronic medical spellchecker on the market and where I can buy it? Starting a new account and it is required to have.


 


Thanks,


Angie


I like the electronic medical books (sm)
convenient to use and user friendly. As for remembering, can't help you with that one. Pushing 60, the old mind doesn't want to work as hard remembering things, but the electronic books are the next best thing.
Electronic Medical Records
Not all EMR systems rely solely on CPOE-type technology. Every acute care account I have worked on in the last 4 or 5 years has an EMR component. The medical records are stored digitally, which allow to any physician with access to the system to pull the patient's record.

The physicians on my current account can input data through point and click (primarily ER notes and radiology which allows immediate access to the information) or they can choose to dictate (H&Ps, consults, ops, and discharges). The dictated reports are still transcribed or edited by MTs.
It is about CLARITY in the medical record.
It makes the medical record easier to read, which means more accurate patient care
A.S. in Medical Record Technology
This included a course in Medical Transcription.  Went to work in a physician's office.  My job title was medical records, but the main component of the job was transcription.  This led to later full-time transcription job. 
Let me tell you about falsifying a medical record
I know first hand it has been done and it was done about me. I had plastic surgery (3 part type) with face lift, tummy tuck and lipo in 2002. The doctor "forgot" to do the face lift. Had paid up front and I asked for the portion of the face lift only returned. He gave me an IOU on his office station but then later would not pay me and get this --- 8 months after the surgery he dictated my report, put in the face lift like he had done it along with the other. Now most people would say well, maybe he got you and someone else confused. Not so- this same physician who was head over the plastic at the hospital called me personally at my home, not through his office, but him personally twice in a threatening like voice when I tried to take thru mediation. I worked inhouse at the time and rather than risk my job, I left it up to Karma. This actually happened to me. I went to the lady over medical records, I worked in the same department, and told her exactly what had happened and she said I could write a note to put in the front of the chart disputing it had been done. Unbelievable, huh?
Protective of the US medical record???
She employed offshore MTs...how protective could she have been?  Are you kidding me? 
The actual medical record contains
those things you mention. The dictated report sometimes does, not that is not often. Some facilities, however, do have the physician dictate everything imaginable and even if it is 1 out of every 10, that is still too much info to let out.
I think that is very unprofessional for a medical record. nm
x
Big deal is legal, medical record which should be the
truth, not a made up report. Medical records are supposed to stand in court just as a sworn statement, that is all. I like the truth and that is the way I try to live my life, not a bunch of falsehoods. I guess others can live on lies if they want.
What will happen to us when Electronic Medical Redords become the norm?

I would love to hear everyones 2 cents about Electronic Medical Records....How soon will this be a problem for us? What will we do after they are in most doctors exam rooms?


Let me know what you guys think...Do MT's have a future? or did I just go thru schooling for nothing ...


I am sorry, I meant Electronic Medical Records, not redords.
nm
Electronic medical records...Is there an option out there for MTSO's SM

I'm wondering if there is a program out there that allows a small MTSO to provide EMR to a clinic of three physicians.


I'm looking for a web-based transcription program that allows me to send/receive dictation on the web and that allows them to access the finished records via the web.


Any ideas?  TIA


eMTS or Electronic Medical Transcription Services
Anyone work for them or know anything about them??
i personally would not want my boss typing my medical record either
nm
ALL of the clinics I work on use SS #s as medical record numbers, and many of them cc to the
patient at their home address, which is conveniently typed at the bottom of the report.  Seems pretty straight-forward to us, then why can't the govt figure this out and put a stop to it?
Approve what? The information used is already part of the medical record and, therefore,...sm
has already been approved or authenticated or whatever one wants to call it.
again, making medical record digital does not affect us.
nm
I use the electronic version as well - no more books for me. All references are electronic! nm
x
I would buy new a Dorland's Medical Dictionary, Stedmans Medical and Surgical Equipment...SM

and Tessier's The Surgical Word Book, 3rd edition.  Books you could buy used I would say would be Stedman's Pathology and Lab Medicine and Cardiology/Pulmonary word book.  These are all the books I use the most during my day.  You could buy other speciality word books as you need them and could probably go used with those.


I wouldn't bother with buying a drug book, new editions come out every year and I just stick to the FDA website and RXList as my drug references.


Also FYI, not a book, but I use my Stedman's Electronic Medical Dictationary a lot.  It's easier to open the program than it is to pick up a huge 30-pound dictionary.


Electronic BOS
If you open your Electronic BOS and do a Control F, you can type in whatever you are looking for and it will take you right to it. Much faster than using the book.
Or Go Electronic

I currently have all of my word books, drug books, and dictionaries on my computer.  About the only book that I may ever need that I don't have on my disk is *One-Word, Two-Words, or Hyphenated?* and my anatomy book, but there are some great websites out there, in addition to Google, that can supplement this when I'm away from home.


One of the last places I went to where I actually had to take work with me was Las Vegas.  We had a BEAUTIFUL view of the strip, so I just turned the hotel desk sideways so that it was up against the over-sized windows and I just typed away!!!  I would rather have been ON the strip, but the view while I was working was definitely different than the trees-and-mailbox view that I get at home!!


I just took my laptop, external ergonomic keyboard and mouse, foot pedal, and headphones.  I had to pack the keyboard in my suitcase and pray that it wasn't crushed, but everything else fit nicely in my laptop bag as a carry-on.  I think the high-speed connection at the hotel was around $20/day, but I had no connectivity problems with it.


A lady I used to know traveled full-time with her retired husband and so she had a new *view* every week!  She had a satellite connection hooked up to her RV and so she would work on the road.  I actually think I might postpone my own retirement just so I can have the experience of working in a different state every week!!


For the record,
the solo-practices and smaller offices are outsourcing to the hospitals...


can anyone set the record for

My record is around 45.  Right now i'm on a report that is up to about 23.  Talk about toxic!


re-record
If re-recording to digital, pretty easy. Play either in handheld or transcriber, and use either computer or digital handheld to capture. Just need the connecting cord between two units - can get at Radio Shack.
Electronic Signatures
The office I work for uses this company's electronic signature.

http://www.crescendo.com/index.htm
What are your thoughts on electronic

When I go to the doctor, he types my visit into the electronic medical record himself as he is speaking with me.  I guess it saves them time on dictating the report .


I always say I will train for something else but it costs to go to school.  I have been in school forever, off a semester, on a semester.  I just hope I can get re-trained before everyone switches to EMR.


anon


Electronic Signature/sm
I just add this phrase to the doctor signature line in the reports "(Electronic signature has been affixed)."  I do not have any special program.  Is there one out there?
What is an electronic keyfobb?
What is a keyfobb..and why is it worth $500?
I went with the electronic fee - $75.00. Some differences in...
benefits, but all in all it's better as far as I am concerned.
Electronic signature
Where can I get information on electronic signatures and HIPAA compliance regarding this? Thanks!
electronic signatures
http://aspe.hhs.gov/admnsimp/faqsec.htm

I found this but there are several other sites available also if you Google HIPAA+electronic signature.
According to my electronic Stedman's.
xxx
expunging record
Just a thought -- a friend had a felony from years ago expunged from her record -- but background checks from then on noted the expungement on her record -- which raised red flags in itself.
another broken record...
me too. It absolutely befuddles me that anyone would be trying to get INTO this field, especially with all the ominous signs that are right out there for anyone to see. I think new moms with babes are just blinded by the idea of "working at home" and can't see the competition they are facing.  Me, I am in nursing school... not an easy job by any means...but I'll be good at it and will find my niche quickly and will always have a job! My biggest account is making noise about getting a VR system. If I wasn't in nursing school, I would be having a panic attack instead!
How did he get his record cleared?
You mentioned that he has a "clean record." I still have this thing on from 11 years ago. Did he have to do something in particular to clean his record or did it just drop off?
We all make dumb mistakes at some time in our lives, eh? LOL
Med Record Retention
That's a very broad question. It's my understanding that the answer depends on the State and the age of the patient at the time of service. Liability required juvenile records be kept forever since it used to be a base could be brought when the injury was first noticed, and that could be well into the adult years.
You have to record to the computer
Get a program like GoldWave (I think goldwave.com). You can buy a plug that goes one end in the transcriber and the other in the computer. One end goes in the transcriber earpiece plug and the other goes in the computer microphone plug.

Then play the transcriber while using Goldwave (or whatever) to record from the microphone input. It creates a WAV file or whatever you specify.
LOL. Did you tell your doctor so he could record it? - NM
NM