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Just like you have it, why change anything?

Posted By: nm on 2009-01-21
In Reply to: Allergies ? - Neta

Subject: Just like you have it, why change anything?

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s/l Bez or all in change
Subject: s/l Bez or all in change

shows the patient in sinus mechanism 66 beats per minute, normal intervals, normal axis.  Voltage criteria for LVH and s/l Bezoiorall is change in comparison to prior EKG dated
Thanks so much to both of you. I will change to 6, 90, and -1. nm
Subject: Thanks so much to both of you. I will change to 6, 90, and -1. nm


I change that to:
Subject: I change that to:

I change elicitable (which to my knowledge has never been a "real word" to "able to be elicited."  My doctor dictator thanked me for this once (I was suprised that he noticed).  I checked this out with several transcripitionists that I have worked with who have lots of experience and are CMTs and they also edit this word to "able to be elicited." 
I'm not CMT and I change that the same way...nm
Subject: I'm not CMT and I change that the same way...nm

      
cc to mL - do you change cc to mL
Subject: cc to mL - do you change cc to mL

according to AAMT or do you type cc


Thanks


 


Would you change this...

Would you change CT head to say head CT? The doctor says CT head.


 


Thanx


VR change
Subject: VR change

He should point it out to his supervisor because it is wrong. I don't care what QA says unless they can show me a resource where they got their information and it checks out. I would also point out to the client this fact. If they don't want to have their transcription correct and concise then I don't want their work. Right is right, wrong is wrong. I am really strong on this especially since the "new AAMT" has made all their "changes" and believe their BOS is the bible. It is not. Many of their "rules" are correct. Many of the are not. Research some of their changes and you will see just how over the top they have gone (it seems to be a control issue and they WILL cram it down your throat). I say that we all research on our own and go to reliable trusted sources that have been proven over time to be correct. The "New AAMT" definitely has not proven itself over time and incidentally they are not there for Americans anymore, they are there for the "overseas community." Humbug on them! Anyone know who could take the place of AAMT for American transcriptionits? After all, we are all Americans here and the language is English.
I would change it to this
Subject: I would change it to this

patients blood pressure readings at home daily have been 90 percent plus.  Would leave as is or change........looks wrong. 


Patient's daily at home blood pressure readings have been 90%+. 


they can change...
Subject: they can change...

depends on what the MD hears on auscultation; that being said, it usually is 3/6, 2-3/6...etc... six is the prime as there are standard 6 heart sounds and the first number being how many of the 6 they hear.
When did p.r.n. change to p.R.n. and why?
Subject: When did p.r.n. change to p.R.n. and why?

nm
I would change it to (sm)
Subject: I would change it to (sm)

CPKs as it appears these labs were done multiple times if they are dictating MBs. I hope I'm making sense.

I'd put, CPKs were high but his MBs were normal.
I would change it to
Subject: I would change it to

Mrs. Smith is a patient on whom I performed rhinoplasty. but that is just me.
I always change that to *in regard*..sm
Subject: I always change that to *in regard*..sm

as for toward/towards, afterward/afterwards......both are acceptable as you said per the dictionary......so it depends on the MD I'm working for...I have one that is a stickler so I give him afterwards and towards as he says them.
Exactly, that is why I don't understand, QA does the same with H&H, they change it H and H. Nm
Subject: Exactly, that is why I don't understand, QA does the same with H&H, they change it H and H. Nm

x
...or 'otherwise no overall change"..??? nm
Subject: ...or 'otherwise no overall change"..??? nm

s
I would change it to ൜ mEq K/L" sm
Subject: I would change it to ൜ mEq K/L" sm

The dictator is "slanging" the order. Since what they're ordering is K (potassium) and that is measured in mEq, and since it has a unit of measurement (mEq), then the "/liter" needs to be abbreviated to /L... imho (wouldn't it be nice if they dictated PROPER medication orders?) :)
I'd change to "mg," as well, but (sm)
Subject: I'd change to "mg," as well, but (sm)

the manufacturer's site would seem to indicate it should be hyphenated, as you originally had it.
http://www.jnj.com/index.jsp?content=product/brands/NEUTRA_PHOS.htm
"Prior" change? nm
Subject: "Prior" change? nm

m
yes, but change it to "are"
Subject: yes, but change it to "are"

nm
it looks weird to me too...I always change it to...
Subject: it looks weird to me too...I always change it to...

it's not necessarily correct - but I think about pussy cats and so the *eye is crusty and has pus* is what I'd put. 
Would you change this sentence?
Subject: Would you change this sentence?

His eye contact was intermittent; most of the time his gaze was fixed on whatever toy he was playing with. 


...most of the time his gaze was fixed on whatever toy with which he was playing?


Not a verbatim account.


TIA


No, I wouldn't change it because
Subject: No, I wouldn't change it because

it is a myth that there is a problem with that sentence structure.
Do I change it when he dictates cc? nm
Subject: Do I change it when he dictates cc? nm

!
I would change it since account not
Subject: I would change it since account not

verbatim. LOL "hook up with"

Doctors are so funny.

If you are safe to change it, do it.
Subject: If you are safe to change it, do it.

nm
Personally, I'd change it to, I was able to
Subject: Personally, I'd change it to, I was able to

get in touch with the patient's daughter, as I am my own QA. My doc lets me spritz up his letters all the time.
unless you change sentence
Subject: unless you change sentence

I'd leave it because he obviously means that patient had no precipitating symptoms of the chest pain, etc.
see messge - I would change to
Subject: see messge - I would change to

arthroscopy of lateral retinaculum.
I usually change this to bear weight
Subject: I usually change this to bear weight


I think your safe to change this one. Verbatim SM
Subject: I think your safe to change this one. Verbatim SM

is not always possible, especially with ESLs. Wouldn't think doc would mind if you made it more understandable and it doesn't change the meaning.
...and no overall change...??? Is the 'z' sound very pronounced? nm
Subject: ...and no overall change...??? Is the 'z' sound very pronounced? nm

s
AAMT is not to blame here (for a change). sm
Subject: AAMT is not to blame here (for a change). sm

I bought the American Medical Association style guide and it, too, reflects these changes. AAMT BOS is just a trickle down from the AMA, Chicago Manual of Style, and the other many sources of which it is comprised. The changes are industry-wide, not just for us, but our work is what is permanent on the patients' charts so we have to pay particular attention to them.
re-x-ray is correct, but I usually change it to x-ray again. I think it looks and sounds better.
Subject: re-x-ray is correct, but I usually change it to x-ray again. I think it looks and sounds better.

x
I would change it to allow. What testament is he dictating from? LOL
Subject: I would change it to allow. What testament is he dictating from? LOL


Fundal height change?
Subject: Fundal height change?

 
...Can't assume that you should change it if not directed to do so. nm
Subject: ...Can't assume that you should change it if not directed to do so. nm

s
Yes. I would change the sentence to read
Subject: Yes. I would change the sentence to read

You Wrote:  "His eye contact was intermittent; most of the time his gaze was fixed on whatever toy he was playing with. "...most of the time his gaze was fixed on whatever toy with which he was playing?  Not a verbatim account.


I would change it to read:  "His eye contact was intermittent.  Most of the time, his gaze was fixed on whatever toy he was playing with."


Rule of thumb: semicolon: punctuation mark that is used in formal writing between two parts of a sentence, usually when each of the two parts could form grammatical sentences on their own. Also, to be grammatically correct, never end a sentence with a preposition.


 


that's right catch it, check it, change it
Subject: that's right catch it, check it, change it

nm
I always change to saturating, per my company QA
Subject: I always change to saturating, per my company QA


I change to saturating/saturation, i.e.,
Subject: I change to saturating/saturation, i.e.,

the patient is saturating 99%. Saturation was 99%. Satting is slang for saturating, sat for saturation.
I need to change it to has gotten. mtroadie, you are great!...sm
Subject: I need to change it to has gotten. mtroadie, you are great!...sm

I think this site should have a board where grammar and style questions can be asked. That is where so many mistakes are being made these days. I think it would be very informative.
"No change" from? "previous" ????
Subject: "No change" from? "previous" ????

Is it an ESL?
just a thought..how about no change to previous?
Subject: just a thought..how about no change to previous?


I agree with Kendra, would change as she has it.
Subject: I agree with Kendra, would change as she has it.


Considering they change things every edition . . . sm
Subject: Considering they change things every edition . . . sm

I'd stick with the national standard for clarity's sake unless instructed to stringently follow BOS.  There is staging that is very involved and would look convoluted without spacing in my opinion; i.e, pT2a pN3 MX, etc.


Can you change your backup speed?
Subject: Can you change your backup speed?


s/l color ometric change?
Subject: s/l color ometric change?

anyone heard the term "good color ometric change" was obtained in terms of intubating a patient?
Rules change over the years
Subject: Rules change over the years

but some rules are that way just because it sounds right. 5 centimeters were injected just sounds ignorant and I don't care who you are, as Larry the Cable Guy would say. ;-)
I would change it to measure and have, as it is plural...nm
Subject: I would change it to measure and have, as it is plural...nm

nm
Maybe it's "no dose" (there was no change in medication. nm
Subject: Maybe it's "no dose" (there was no change in medication. nm

x
Thanks, one QA I had used to change dilatation to dilation, thanks for the input. nm
Subject: Thanks, one QA I had used to change dilatation to dilation, thanks for the input. nm

x