Hi friends,
I have come in many dictations where there is a clipped voice file and many a times the dictator mumbles and corrects and not consistent with the content. For example, he says about the prob being in the left and in between in the examination part he mentions that there is tenderness and swelling on the right and then again in impression he says it is left and so on. In this case, naturally we cannot come to conclusion or take decide on our own. These cases unless very sure, we send a note. Even when almost sure of the correct side, I always send a blank with a note. What do you guys do? Do you go ahead and correct or do you leave them for the physician to fill in or (rather decide! I wonder what happens if he also forgot including the patient). In clipped sentences and very distorted voice quality what do you guys do? I would like to know what others do? Many a times I wanted to change because I was sure, but then I did not want to take the risk.

Good day. :p

Hi!
You are right to leave blanks and send notes to dictators, especially when they are inconsistent as to what side they are referring to. I have run into this problem many times myself and although I am pretty sure of the correct side or whatever, I never assume. These documents are too important. We have dictators who jump between left and right, up and down, who swallow letters and chop off syllables but I think they are just so busy and not concentrating and trying to get through this part as quickly as possible. At our hospital, we usually type what we are sure of, leave blanks and have the dictator fill in the correct word. If the dictation itself is so mangled or distorted for some reason, that it is practially impossible to make out, the dictator may even be asked to redictate. Hope that helps.

Bridget - It helped me! I've often wondered the same thing ~ thanks for clarifying!
Amy

We had a lot of "rights" and "lefts" in radiology and made a lot of corrections - because we knew what the radiologist should have said.

Also we worked in the department and had the advantage of checking the films to see what was really x-rayed if we weren't sure.


--- if you were typing a right wrist x-ray that showed swelling only - no fracture or dislocation, and the radiologist said, "Impression - Normal right foot." Would you correct it? We did -

If we had gone back to the radiologist - he would have said, "Duh!"

I supposed a lot of your making corrections depends on where you work - whom you work for - how long you have worked for them - what types and the seriousness of the reports you are doing -as well as the personality and expectations of the doctors you are transcribing for.

I typed 165 reports for one radiologist one day - and 90% of them were negative fingers, toes, knees, ankles, etc. I imagine I made quite a few "left" and "right" corrections that day.

Sometimes working in an office and having charts available can help us make determinations. I find myself using charts checking medications a lot.

On the other hand, there have certainly been many many times I have left notes on reports. Sometimes you just can't be sure....or even close to sure.

Hi Guys:
Yes, I certainly agree with Mugwamp. If you are able to document, with a chart or films or whatever, the correct part, then certainly I would correct the dictator's mistake. But, what I was referring to was when the dictator gives the procedure as say, left total knee arthroplasty and then says, in the body of the letter, the right leg was prepped and draped and refers to the right leg throughout the report...or dictates fracture right olecranon as diagnosis and then goes on to dictate treatment of the left arm. Having no access to charts, I would question. But for the most part, I do correct mistakes and that has always been appreciated. We have been told by many of our dictators that, as good transcriptionists, we make them look good by correcting their grammatical errors. Also, I should probably add that we have to send very few reports back for correct information.

I agree - I think that if a report "contradicts itself" on an important issue and you have no way of knowing which part of the report is correct, you need to check with the person who dictated it.

But then at times (with something that is not very important).... we can be a little creative.

I type cardiology - the patient's are at our office for the diagnosis and treatment of cardiac disease. I typed a report recently that mentioned that a patient had a left knee fracture four years ago...... then under surgeries - the doctor mention that the patient had had "right knee surgery for a fracture about four years ago."

Well - the patient's knee fracture four years ago is not very relevant to his current medical problems and care. So (because the doctor/dictator won't even be in the office for more than a week) I just typed knee fracture in both places and got the report out to the referring physician so he can continue with his care (and I'm sure his primary physician probably has reference to that same knee fracture in his reports).


Every case is different - and I think that one of our jobs as transcriptionists is to make "good decisions" as these problems arise.

I think the more experience you have and the longer you have worked for the same doctor(s), the less unsure you might feel at times.

A good rule would be "When in doubt - check it out."

Hi


You hit the nail on the head! That is what makes a medical transcriptionist a medical transcriptionist, in my mind. To be able to know when a mistake has been made and to be able to make "judgment calls" appropriately. These things are learned in life experiences, I guess you would say, and the longer you are in transcription, the easier the calls are made. But, that is probably the part of my job that I love the most.

Hi Carol and Bridget,
It did take a couple of days to catch upon the replies, but then when I did "Wow!" I really had a nice read. I take a lot of pride in our work as MTs. You both are right about how we cannot take decisions when in doubt and when there are no documents at our reach for clarification and of course when not knowing your doc properly. So I had been right about sending blanks and notes for further clarification. But then the problem with us is we are a foreign country people doing medical transcription for US hospitals and their docs. So though sure sometimes, we do not want to make the corrections because it might be against the rules, or may be the physician would not like it or we might sometime be overconfident and endup wrong. So blind rule is leave note when not sure or when there is discrepancy in the content. Any way that help from your side was very enlightening. I wish to have more interaction with you guys because I love the work as well the people and the country we are working for. More awareness and interaction is the best way to be a good MT. Right?

Good day.

RN