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...in the client specifics very clearly. Otherwise, QA should let it slide. nm

Posted By: wanderer on 2007-09-20
In Reply to: Just comes from experience. Every job I've worked has handled it differently. - Every one! Agree, fight this one unless it's in

Subject: ...in the client specifics very clearly. Otherwise, QA should let it slide. nm

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Do it per client specifics.
Subject: Do it per client specifics.


First, see your account specifics or client preferences.
Subject: First, see your account specifics or client preferences.

If no mention is made about it, I would type it as a numeral for anything less than 10.


Wild guess. Slide done.
Subject: Wild guess. Slide done.


slide-back patch????
Subject: slide-back patch????

Radiology -arteriogram - hemostasis achieved with direct pressure and _______ patch.  s/l slide back, side bag, side duct maybe..
Question about slide done breast discharge sm
Subject: Question about slide done breast discharge sm

Slide was done of this area, with s/l "cyto Fixodent" done. I can't find anything, other than related to Fixodent for false teeth. Thanks for any help.
O'Brien test is of anterior shoulder slide
Subject: O'Brien test is of anterior shoulder slide


"Cervix does not slide to the pts left. Patch and vaginal cultures obtained." Is this right?
Subject: "Cervix does not slide to the pts left. Patch and vaginal cultures obtained." Is this right?


Esophagus pathology report - s/l "Jimsem" stain with positive control slide. ??
Subject: Esophagus pathology report - s/l "Jimsem" stain with positive control slide. ??


More specifics?
Subject: More specifics?

Is it a myringotomy and tube insertion? Is it being pronounced bog or b-o-g?
Also, don't know about your account specifics but
Subject: Also, don't know about your account specifics but

I would use 1.5 cm, as in 1.5-cm "hypoechoic" mass...decimals for metric...
Account specifics - if they want 's that's what they get. SM
Subject: Account specifics - if they want 's that's what they get. SM

That's what is in AAMT BOS - Depends on client preference, so, no, she is not wrong


All according to your account specifics. Like
Subject: All according to your account specifics. Like

I said below, we do not use slang, therefore use saturating; however if verbatim, then satting is correct.
What do your account specifics say? nm
Subject: What do your account specifics say? nm

nm


Account specifics would dictate whether you sm
Subject: Account specifics would dictate whether you sm

write it out or abbreviate. The abbreviation for beats per minute is bpm. Ask your QA person for approved abbreviations for this account (accounts will differ sometimes which can make us crazy).

do you have account specifics to read?
Subject: do you have account specifics to read?

on most accounts it is acceptable to leave 1-2 blanks. If you really think it sounds like minute, then put that.
Depends on account specifics. sm
Subject: Depends on account specifics. sm

In general, we are to write out the term in full the first time it is dictated for clarification. Then, if abbreviations are dictated later on, it is okay to use the abbreviation. Again, you must abide by account specifics. Ask your QA person to be sure.
also I should have said check your account specifics - SM
Subject: also I should have said check your account specifics - SM

Each doc and/or hospital may want classes and grades a certain way. It is a good idea to make sticky notes like Another KSMT said.
same here - depends on my account specifics nm
Subject: same here - depends on my account specifics nm


I would check your account specifics...(nm)
Subject: I would check your account specifics...(nm)


Check with your TL on the specifics of the facility.
Subject: Check with your TL on the specifics of the facility.

Most hospitals I have worked with prefer cm2. 


Almost depends on account specifics
Subject: Almost depends on account specifics

Some of the verbatim accounts allow for medical jargon, so if in the body of the report they said he was given 2 amps of bicarb, I would probably just leave it at amps. If this was in a medication list, as on admission or discharge, I would probably write it out as ampule(s).
depends on account specifics, whether verbatim, etc.
Subject: depends on account specifics, whether verbatim, etc.

x
Although I would double check your account specifics. SM.
Subject: Although I would double check your account specifics. SM.

Some docs might prefer you to spell it out for them or have an specific way they want it typed.
yes, but without specifics it's impossible to know if you're hearing it right
Subject: yes, but without specifics it's impossible to know if you're hearing it right


check your company's Account Specifics, if you can
Subject: check your company's Account Specifics, if you can

nm
That's what I mean by "ask your QA!" Account specifics dictate style, sm
Subject: That's what I mean by "ask your QA!" Account specifics dictate style, sm

but the AAMT BOS dictates what is correct for the industry, getting its information from sources such as the Chicago Manual of Style, the American Medical Association book of style (which I own), etc. As the poster below states, Joint Commission goes by BOS and does not like "same" or abbreviations for diagnoses, impressions, op titles, etc. They will randomly choose patient charts and go through them to check things like this! It's the Joint Commission which recommends or removes hospital accreditations--a very powerful entity.

So, ask your QA what the account wants. If they want "same," give them "same." For other accounts, do it the correct way.
depends on account specifics, but I usually type 3-1/2 months NM
Subject: depends on account specifics, but I usually type 3-1/2 months NM


Got it. Thanks again. There are no account specifics, so I like to type verbatim just to be safe.
Subject: Got it. Thanks again. There are no account specifics, so I like to type verbatim just to be safe.


It all depends on your account specifics. If they use BOS, then use mL. I've had verbatim accou
Subject: It all depends on your account specifics. If they use BOS, then use mL. I've had verbatim accounts

with no BOS wanted per the client, regular accounts who do use BOS and others that do not want it, and others that "just type what I say." So, like I said, refer to your account specifics.
Always go with account specifics, regardless of what BOS recommends. Good luck! (no message)
Subject: Always go with account specifics, regardless of what BOS recommends. Good luck! (no message)

X
Depends on your account specifics. If they allow you to expand, that's fine, but it is straight
Subject: Depends on your account specifics. If they allow you to expand, that's fine, but it is straight

hardcore verbatim you have to leave it as is, whether it looks ugly or not.  I know, I really don't like it when they abbreviate left and right, leave words off sentence structures so they can speak faster and get it over with.



Both are correct, just type it according to your account specifics, some like disc and other disk.
Subject: Both are correct, just type it according to your account specifics, some like disc and other disk.


That's right! Client's way is the right way, sm
Subject: That's right! Client's way is the right way, sm

as they're paying for it. However, when I give answers here, I go by BOS as we all work for different clients. You're right, though, the client's preference prevails, right or wrong, or in-between.

Not as far as MY client wants it..
Subject: Not as far as MY client wants it..

nm
Up to client
Subject: Up to client

I have been doing hem/onc for 7-1/2 years, and it seems as though every account I have worked on uses their own style, i.e., currently I work on M. D. Anderson Cancer Center and they want stage IA, IIB, IIIC, etc., written as stage I-A, II-B, III-C, etc., plus a few other things that are done differently than normal. The client is always right, so you have to be sure to follow their guidelines.
Nothing to do with the client. If
Subject: Nothing to do with the client. If

x
That would be per the client, but most
Subject: That would be per the client, but most

hospitals I have worked for want it under Labs.
That would entirely be per the client.
Subject: That would entirely be per the client.

We type 2 p.m. unless they say "O'clock" and for 08 per BOS I believe 2008 would be correct.
Per your client, but not normally unless in an
Subject: Per your client, but not normally unless in an

x
It is however your client wants. However,
Subject: It is however your client wants. However,

how do you know if you expand to Psychiatry or Psychology, Psychiatrist or Psychologist???
Not unless your client wants it. Where I
Subject: Not unless your client wants it. Where I

x
You do what your client wants.
Subject: You do what your client wants.

x
It is all according to the client. Some want
Subject: It is all according to the client. Some want

numbered lists, some don't. Need to check with them.
It is all according to the client. Some want
Subject: It is all according to the client. Some want

numbered lists, some don't. Need to check with them.
It is all according to how your client
Subject: It is all according to how your client

wants things done. Some want headings for everything, some want verbatim. Need to check with your supervisor and/or client.
if your company or client is using BOS
Subject: if your company or client is using BOS

as a guideline, per page 283 of 2nd ed, you DO use an apostrophe to form the pleural of single-digit numerals. In fact, they use that same example, "4 x 4's."
might depend on client
Subject: might depend on client

I have been using weightbear and weightbearing for the past two years and neither the QA or the client have every complained or requested otherwise. matter of opinion, I guess.
it's really client preference.......nm
Subject: it's really client preference.......nm

.
Definitely client preference, if they have one, but -- sm
Subject: Definitely client preference, if they have one, but -- sm

barring that, the AAMT has come out saying that "disk" is preferred over "disc" (for whatever that's worth), though both are still acceptable.

I've had some clients with a preference for "disc" with respect to the eyes, and "disk" when referring to the spine, but the vast majority (in my recent experience) have shown a preference for disk in all cases.
Best to ask your QA how the client prefers this to be done. nm
Subject: Best to ask your QA how the client prefers this to be done. nm

x
Client preference here. nm :)
Subject: Client preference here. nm :)

nm