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Are We Falsifying Records?
By Burt Danet, 2/96:
This is an interesting question. When preparing for a review for
accreditation by JCAHO, hospitals often request the transcriptionist to
change the date of transcription to match the date of the report when the
dictation may occur days, weeks, months later, to keep the record
"looking good" in time for the review. This flurry of activity
does involve falsifying the facts.
Changing Date of Transcription
3/14/96, from Mary Morken
While researching this issue, we have learned
that state regulations determine some of these standards for date of
dictation. In regard to date of transcriptoin, I talked with two
physicians and about eight MTs from different states; all agreed that MTs
should not change the date of transcription. If requested to do so, it
is recommended that the MT respectfully decline and ask that the policy
3/6/96 from Tillie Horak, email@example.com
the JCAHO 1996 Comprehensive Accreditation Manual for Hospitals,
Section IM 7.6, Pg 432, records must be completed within at most 30 days.
The hospital must measure delinquency at least every three months. They
must also have a method for the author to "acknowledge the document after
it is transcribed."
From Liz Hugger:
I've been asked to do this also but told them I am legally prevented
from changing records. Since the work is sent to them by modem, let
them change the dates if they feel they must, but my archived records
for my digital dictation system will show when the report was dictated
and when it was transcribed anyway, so they're not really fooling
anyone should this be further investigated.
Abortions, Pro and Con
4/96, From Cynthia Lewis
Have any of you experienced MTs run into an
problem while working for an OB/GYN concerning abortion? Specifically,
have you had to address the problem of not wanting to transcribe an
From Bill Bentsen
We are transcribing the doc's dictation, not
performing or condoning abortion. As a professional, that is our job,
From Mary Morken
Regarding the question of transcribing abortions,
I've heard different views on this among MTs. Whatever our beliefs
ethically about the right or wrong of different kinds of abortions, it is
not always clear in the dictation just which kind it is, or whether it
even complies with state laws or not. Reasons for procedures are
sometimes stated with finesse for insurance purposes.
Whatever unethical practice we might feel a certain procedure to be, we
are typing the legal record, not performing the operation, and the record
could eventually become part of a case against the doctor, so it is
unclear which side we would be helping by typing it anyway.
Here's my question: Is there anything we wouldn't type? Are we
implicated morally at all just by having our initials on it? What if we
could tell it was an assisted suicide? What about the doctors who
constantly slant their diagnoses for insurance and Worker's Compensation
purposes, depending upon which side they are on? What do you think?
4/96, From Alisha, firstname.lastname@example.org
It is not my
place to judge what the doctor and patient decide - in
other words, it is none of my business. I am merely trying
to accurately transcribe what is dictated. If it is a
problem for any transcriptionist, she/he should immediately
inform the physician, perhaps even change jobs or clients -
that is her/his decision and none of my business either.
4/96, from Mary Booth, Edna@aonline.com
Our job is to do medical transcription. Whatever the issue, we are not
performing the procedure, we are just transcribing the legal document.
Period. I worked in a Catholic hospital where many docs did tubal
ligations. We didn't do abortions but an awful lot of tubal ligations.
It was obvious to us what was happening, but my job was to transcribe the
report. I believe my personal opinions should not be a factor when I do
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