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True, it is in all what you are allowed or not

Posted By: see message on 2008-04-30
In Reply to: I am allowed to edit and correct - katmt

Subject: True, it is in all what you are allowed or not

allowed to do. However, at one of the first hospitals I worked for (back in the early 80s) for example, we had a doctor who was constantly using abbreviations which we were not allowed to do in diagnosis. I will NEVER forget this. His diagnosis was "P.M.S.O.B." The transcriptionist, of course, changed this in the diagnosis to read "Shortness of breath at night." He flew off the handle - this abbreviation meant "poor, miserable, son of a B****" and that is what he wanted in the chart. It was referred to the Hospital Director who told our department manager that even though this was definitely not correct, he dictated it and wanted it there and there was not much we could do about it if we wanted to keep our jobs. This is a lesson that taught me never to second guess a physician. Granted this was not at all politically correct (we didn't have that term back then), but that is what he wanted, so I don't change anything in that vein - I may question it and flag it for the higher ups, but I don't change it.


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Subject: I am allowed to edit and correct

I am allowed to make changes to what he says, which is why I asked the question. I am allowed to edit and change what the doctor says and how he says it - and I do a lot of that in the course of the day because some of the things he says are just a mess. "Retarded" did seem a little derogatory to me and I think I will put it in better terms than that.

I guess it comes down to what the rules are that you work by - whether you can edit or if you are verbatim. If it was verbatim I wouldn't have questioned it (even thought I personally feel it is insulting) but since I have the option to change it, I was just wondering what the correct term was now because I know it keeps changing. Thanks for all the opinions!
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