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it would depend on what type of an account you are

Posted By: me on 2007-05-16
In Reply to: with time are you supposed to put the word hour after the time, i.e. 1600 hours - babyfer

Subject: it would depend on what type of an account you are

working on. and your company specifics. if its verbatem..then you put the word "hour" whenever the dictator dictates it.  if he just says something like "time seen...0600 hours" then:


TIME SEEN:


0600 hours.




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It may depend on the account, but I think most
Subject: It may depend on the account, but I think most

people add dosage.   The doctor is only one of many people who read the chart. 
Would depend on your account and whether they allow headings where necessary or not. If heading is w
Subject: Would depend on your account and whether they allow headings where necessary or not. If heading is warranted, I would use CLOSURE.


It would depend on your client profile for that account. I have never run across numbers within the
Subject: It would depend on your client profile for that account. I have never run across numbers within the axes, it would normally just be commas between each diagnosis or periods if that is what the client calls for. Check with that CP if you can.


I always use combined forms ie. posterolateral, but would depend on your account i suppose. nm
Subject: I always use combined forms ie. posterolateral, but would depend on your account i suppose. nm


on my account can only type PRN, no periods. sm
Subject: on my account can only type PRN, no periods. sm

Everything can't come from the BOS. Some things we do have to 'wing it' so to speak. I have a verbatim account and can only type PRN, no periods, all caps, so that's how it would be done. P.r.n. Tylenol doesn't look right, so I would have to put it PRN Tylenol.
Even if it is a nonverbatim account, you type
Subject: Even if it is a nonverbatim account, you type

x
If you are on a verbatim account, type exactly what is dictated.
Subject: If you are on a verbatim account, type exactly what is dictated.

If you sense a discrepancy, you can flag it for your QA department.
I am on a verbatim account so I have to type it either way it is dictated L4-L5 or L4-5. As far OB/G
Subject: I am on a verbatim account so I have to type it either way it is dictated L4-L5 or L4-5. As far OB/GYN, G2, P3 or gravida 2, para 3 means with the 3-0-0-2: 3 live births, 0 preterm births, 0 miscarriages, 2 living children


That's the way I type it when the account is verbatim. Otherwise, you could correct to incised an
Subject: That's the way I type it when the account is verbatim. Otherwise, you could correct to incised and


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.


type "the year" if it is a verbatim account.
Subject: type "the year" if it is a verbatim account.


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.


account specifics for that particular account should state how it is to be typed. nm
Subject: account specifics for that particular account should state how it is to be typed. nm

.
Would depend on what they are doing?
Subject: Would depend on what they are doing?


That would depend on what the
Subject: That would depend on what the

normal said.  For example, if it says "breasts are soft and pendulous", you might want to leave that out.  Men generally don't have pendulous breasts, not even ones with gynecomastia.  If it simply refers to the fact that there are no masses or nipple discharge, I would probably leave it in.


If you're still unsure, you can always flag it and find out for future reference.


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.
I think it would depend on the drug....
Subject: I think it would depend on the drug....

??
yes, me too - also it may depend on client preference NM
Subject: yes, me too - also it may depend on client preference NM


it may depend on a facility rule
Subject: it may depend on a facility rule

our facility requires a hyphen for any statement of __ to__ so for us it would "x4-5" days.
That's okay...I have days like that myself and I can always depend on help from my fellow MTs. nm
Subject: That's okay...I have days like that myself and I can always depend on help from my fellow MTs. nm

nm
Depend if the doctor says it and it is a verbatim acct.
Subject: Depend if the doctor says it and it is a verbatim acct.

x
Would depend on the context. In the office setting, it could be. I don't
Subject: Would depend on the context. In the office setting, it could be. I don't

s
typing med list and thru the mumbling s/l FILLA-DEPEND ER 5 mg. nm
Subject: typing med list and thru the mumbling s/l FILLA-DEPEND ER 5 mg. nm

x
Depends on the account: My verbatim account is VERBATIM and other accounts I put 3100
Subject: Depends on the account: My verbatim account is VERBATIM and other accounts I put 3100


account?
Subject: account?

NM
On the account I'm on they want us to
Subject: On the account I'm on they want us to

type out potassium chloride. Which I'm only too happy to do with a shortcut, LOL.


The account that I am on
Subject: The account that I am on

The account I type is "almost verbatim".  We type subcu, but in the lab values we have to expand the workds (alkaline phosphatase, et cetera).  If a word is dictated that is not a known abbreviation, we have to type it out.  I think each account is different, and as the other poster said, they should have given you an client form so that you would know what the hospital expects. Sounds like your guy kinda got his tail in a crack and felt like he needed to unload on a poor, innocent MT who was just trying to do her job!  Hang in there!      W'e're cheering for you!


 


g is okay per BOS, but I have an account
Subject: g is okay per BOS, but I have an account

where the client profile forbids it and it must be written out as grams. Maybe yours is account specific too.
I am on a new account and need some help here.
Subject: I am on a new account and need some help here.

Patient has a mild s/l list to the left.  This is orthopedic.  I have postural list in my Stedman's Ortho book.  Could that be it? 


New account for me/sm
Subject: New account for me/sm

All I know is baby had Norwood procedure on her heart.  Is it some sort of monitor?
Does your account use the BOS 2?
Subject: Does your account use the BOS 2?

That's the source of the "Don't capitalize it when it stands alone" rule. My suggestion would be to follow BOS if your account uses that and to be consistent. Stedman's is (are?) notorious for inconsistency with this sort of thing.
In verbatim account... HELP PLEASE

She is sating(satting) 98% on room air?


I want to change, but on verbatim, I suppose I'm not supposed to, right? I'm relatively new to this and not sure.


 


Verbatim account
Subject: Verbatim account

How would you type... as I have it?


If you expand it (and you should if your account allows), sm
Subject: If you expand it (and you should if your account allows), sm

it should be "cardiac catheterization," not "cardiac catheter." 
ESL help..with verbatim account..
Subject: ESL help..with verbatim account..

would you type re-meet? remeet? or change to meet again... It is vebatim, but I'm not used to that yet... need seasoned advice!  Thanks!
Ask your QA what the account prefers. If it's sm
Subject: Ask your QA what the account prefers. If it's sm

verbatim, I would use T-max if that's what was actually dictated.

On a verbatim account, would you
Subject: On a verbatim account, would you

actually leave this sentence as is?


She puts Neosporin on it, and she reports that in the morning it looks pussy.  


 TIA for any input.


Only if the account is verbatim would I
Subject: Only if the account is verbatim would I

type 5 foot. Should be 5 feet.
Thanks. Didn't know it. New account (nm)
Subject: Thanks. Didn't know it. New account (nm)


You might want to see if you can get this clarified for your account since
Subject: You might want to see if you can get this clarified for your account since

there is a product called ZAP and I don't know what your doc was using it for. :-)
What abbreviations are and are not appropriate will be different for each account sm
Subject: What abbreviations are and are not appropriate will be different for each account sm

Go with what your QA tells you.  It may be acceptable but the doctor may not like/want it done that way.  I've found every account has different rules and preferences.
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...
It is a verbatim account so I can't add the bag ;) sm
Subject: It is a verbatim account so I can't add the bag ;) sm

He just said the patient was *ambued and could not be intibated due to facial trauma* 


So, looks like this is one of those that is up in the air and probably something to talk to company QA about? 


 


Is this a verbatim account?
Subject: Is this a verbatim account?

If not, it would make more sense like this:

It would help beneficial organisms AND commensals bacteria colonize his colon and help as a first line of protection against disease.

If not, then I would type:
It would help beneficial organisms, commensals bacteria colonozie his colon and help as a first line of protection against disease.

Since they want the beneficial bacteria and commensals bacteria to colonize his colon, there is no need for a comma before colonize.
ONLY if your QA, account, or docs want it to be so. Not everyone
Subject: ONLY if your QA, account, or docs want it to be so. Not everyone

s
Of course you first and foremost do what your account wants sm
Subject: Of course you first and foremost do what your account wants sm

and as I said, that is how I was taught.  Now, every account I've done wants it that way and it is that way on the Dangerous Abbreviation list...AND that's what I said - use mL not cc. 
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


I hear it a lot on this account.
Subject: I hear it a lot on this account.

but I have looked on previous reports and seen where MTs type Mabex but I cannot reference it so I blank it and send it on. Just wondered if anyone else heard of it.
And did you say what kind of account
Subject: And did you say what kind of account

or what the specialty is? If you hear it a lot, it is probably related to the specialty you're doing.
If the account is verbatim, I would say OK
Subject: If the account is verbatim, I would say OK