Editing Dictation
Proofreading
4/96, From Alisha: Ah, what differing opinions we all have, and we even
differ with ourselves. What does the doctor prefer? Does he expect to
have articles like "the" inserted? Most of the time, I go on instinct.
Once I know the way a doctor dictates and what he prefers, I will insert
the articles and sometimes verbs. I do correct tenses when it's obvious.
For example, in a discharge summary for a patient who died, I do not type:
"The patient is an 83-year-old male who suffers from hypertension." That
seems too ridiculous when I've just been told this is a "Death Summary."
I change the tenses of the verbs to "was" and "suffered".
At times, I change syntax. Of course, I have transcribed for companies
who prefer their work "verbatim" except for SOME grammatical changes - and
I have discovered that those depend on the quality control editor.
If you don't do as your supervisor suggests will you still get a raise at
the end of the year? Will you be fired? Is this a control fight with
your supervisor? Having been in some of those myself and having been much
more opinionated in times past, I can understand both. I have walked from
jobs for being told, "You have to do this," and having disagreed strongly
with the "have to" as being ridiculous or beyond my desire to change.
Now, I find I am little mellower.
There's too much more serious happening than correcting grammar. Of
course, if you are uncertain about changes - the old adage, "When in
doubt, don't" is the best course. Simply tell your supervisor you don't feel
competent to edit the doctor's dictation, as they are the expert.
3/96, from Burt Danet:
Liz wrote, "This is just one more thing to
convince me that we could put a paragraph about a little red truck in the
body of these reports and it would go unnoticed."
It's not NOT being noticed that is of concern, it is when the story about
the little red truck is flagged for some reason - by the doctor, by the
lawyer, by the medical records director, worse yet by the patient, by
whomever - that is of concern. While the medicolegal concerns may not
come up frequently in every day practice, the potential for them is always
there and we just have to make sure what we are doing makes sense as well
as the ear-fingertip-report connection. One would hope that the work does
not contain such a gross error as the one you point out, and that is why
the eyeball, as well as the ear, comes into play as a crucial ingredient
to ensuring high quality, accurate and sensible output.
3/96, from Mary Morken
It is hard sometimes to type stuff no one ever
reads. QA may read one out of 500, Insurance people one second for each
page they turn, H&P maybe by hospital staff if on time, patients maybe 10%
and lawyers even less. Maybe it's like when you are new in the military:
You work hard NOT to be noticed!
3/96, from Chuck Sigars:
I have been transcribing for almost 20 years
and while I feel a strong responsibility to edit for clarity and to help
when a physician makes a grammatical, chronological, male-female,
left-right, etc., etc., error, OR to help when he/she is obviously tired,
if a dermatologist dictates that a patient's face was as red as "a
baboon's butt" and sounds reasonably sober, I am pretty inclined to
transcribe it. I might flag it for his attention, or a medical records
person's review, but to omit it because I might find it inappropriate is
arrogant, not to mention very questionable from a legal standpoint.
3/96, from Debbie Hahn, DebbieCMT@aol.com:
I tend to agree with you.
Back when I was just starting out, 20 or so years ago, I was chewed out by
a doctor because I left out his expletive in an office note. He read the
note on the patient's next visit, noticed the omission and informed me
that he had dictated it and fully expected it to appear in the dictation.
I realize he's probably in the minority, but that incident has always
stuck in my memory and made me tend to err on the side of leaving
dictation as dictated. If a doctor personally asked me to edit his work
more intensely, then I would do it, but I've never had that happen, and
for the past several years I've been working on accounts where I have no
contact with the doctors. I tend to be very conservative in my editing -
as you said, in obvious cases of left-right, male-female confusion, etc. I
will correct something, but I am very conservative even when it comes to
grammar corrections and recasting sentences. For one thing, once you start
editing their words, it's hard to decide where to stop, and I think that
can be the biggest downfall. I have had beginning transcriptionists ask
me about editing a doctor's dictation because "obviously he really meant
_____ instead of ______", and sometimes they don't know where to draw the
line. After all, these doctors have been to medical school and we
haven't!
3/96, from Janie Gilbert:
I have a friend who transcribes for an OB/GYN clinic. She changed "I hurt
the patient during the pelvic exam," to "The pelvic exam was painful for
the patient." In this case, editing helped clarify what was meant and
avoided painting the doctor as a masochist. Of course, one can always
flag such items for the dictating MD but I believe in the case of office
dictation, the easiest way is to do as above and later notify the doctor
so he can be aware of what's occurring in his dictation/transcription.
Common errors made in medical dictation and how they can be edited:
The patient smokes two packs per day for 30 years.
--The patient has smoked two packs per day for 30 years.
After informed consent was obtained, the patient was taken...
--After informed consent was given, the patient was taken...
The patient may weightbear -- The patient may bear weight.
The patient was consented -- The patient consented.
The patient was consulted by psychiatry -- A psychiatric consultation was
obtained.
The patient was explained... -- It was explained to the patient...
The wound was pussy. -- The wound was purulent.
Sitting in the left arm her blood pressure is... -- In the left arm while
sitting her blood pressure is...
Status post history of... -- History of...
Previous past history of... -- History of...
History of tonsillectomy in the past. -- History of tonsillectomy.
Once this was accomplished,.. -- Then... (when repeated over and over)
At this point in time, -- At this time,
The risks and complications were explained... -- The risks and possible
complications were explained...
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