Sunday, January 11, 2009

Medical Transcription Guidelines -11

Editing

1. Every dictator has at one time or another misspoken and said something like, "The patient smokes two beers a day and drinks two packs," or refers to the surgery on the left leg in one paragraph and the right in the next. Dictating physicians are counting on the medical transcriptionist to be alert and, when necessary, to correct their mistakes.

2. The experienced medical transcriptionist, with a firm grasp of medical language and terminology and familiarity with the dictating physician's preferences, may edit in various ways throughout a report.

3. Where warranted, the transcriptionist may add conjunctions (and, but, for, or, nor), prepositions (of, to, in, on, with), articles (a, an, the), pronouns and nouns as the subject of a sentence, and verbs to complete a sentence. It is acceptable, however, to type as dictated, to preserve the style of the dictator.

Dictated: No tenderness present over chest.
Transcribed: No tenderness is present over the chest.

Dictated: Came in with chest pain.
Transcribed: The patient came in with chest pain.

Dictated: No tenderness on palpation
Transcribed: No tenderness was elicited on palpation.

4. As a general rule, the history portion of medical reports is dictated in the past tense. Some physicians, however, dictate in the present tense even when discussing past events. While some dictators expect the transcriptionist to change the report to past tense, others want the report to be transcribed as dictated.

5. Some dictators switch tenses within a report. The transcriptionist may elect to transcribe as dictated or edit the report to one tense for consistency, if the dictator's preference is not known. Be careful, however, as tense may change from present to past to future within a single sentence and be entirely appropriate.

The patient comes in today, stating she had a bad fall yesterday and will not be able to rest until her pain is relieved.

6. Editing also includes watching for medical inconsistencies within a report, such as a hysterectomy reportedly done on a man, or different ages given for the same patient within one report, or a surgery that begins on the left leg and ends on the right. If an inconsistency cannot be resolved, the word or phrase in question should be flagged to the dictator's attention for clarification.

1 comment:

  1. Great thoughts you got there, believe I may possibly try just some of it throughout my daily life.

    medical transcriptionist

    ReplyDelete