I’ve been working a ton lately, so I’ve got medical transcription on the brain. I transcribe for a bunch of different doctors in a few different clinics, and at least once a day I have to stop and write down something that interests me. Sometimes these things are funny:
CHIEF COMPLAINT: The patient has been seen by me previously. (The Chief Complaint is the reason the patient has come in for a visit.)
She has a point on her back where if she touches that point it causes her to have nausea. I indicated to her she should probably not push on that spot.
It actually only happens when she gulps cold beer. I told her to stop doing that. (Docs really do say that! Haha!)
Sometimes they are poetic:
Six-two-nine-six Cedar Canyon Road. Say it again:
Six-two-nine-six Cedar Canyon Road
Pepcid utilized in place of Prilosec given the issues of Plavix.
Counseling concerning cryotherapy.
Sometimes the things I write down are things that make me think and sometimes make me angry/sad:
She was advised that there would be no physician / patient relationship as a consequence of today’s visit. (You and the doc were just having a good time at that visit . Don’t worry, it’s not you, it’s them.)
She does indicate she was treated rather rudely by the Emergency Room personnel with regard to her pain medications, and I indicated to her that is just an ongoing problem, and just simply demonstrates the ignorance of other providers with respect to pain medication.
I do highly recommend that he obtains the recommended x-rays for his cervical and lumbar spine, regardless of ability to pay. (Sometimes the docs are a little out of touch, telling a pain clinic patient to just find another job that is less labor-intensive so that they won’t be hurting as much. Oh, is that all?)
And now, a list of potentially bad/harmful typos have to constantly watch for in my typing:
addition instead of addiction
not instead of now
shit instead of this
slut instead of flu shot (inexplicably!)
Shitory instead of History
I read somewhere recently that some clinics and doctors are doing the dictations while the patient is still in the room, or otherwise letting the patient see the dictations, or by just typing up the report while the patient is there. My providers at Group Health did the latter. Of course, a patient can see these at any time by asking for their medical records, but not many people actually read their medical records. The idea is that if a person hears or sees their doc describe their conditions honestly in bare medical terms, they will pay more attention. Certainly there are doctors who sugarcoat things, or at least use different terminology in their reports than they would with a patient. An overweight patient is not likely to be called “obese” by their provider face-to-face, but it will probably show up in the record like that. Would this cause patients to be more concerned about their conditions and take more proactive measures, or would it cause doctors to soften up their words? Well, either way, voice recognition software has a loooong way to go in the medical transcription field, so I’m not too worried about losing my job to docs who transcribe. I think most doctors wouldn’t be thrilled about the idea anyway, because it’s just more paperwork, which I know is a pain in the ass for them, seeing as my whole job is doing that paperwork to save time for someone else.
I’m going to be in my hometown in a couple of days and I’m going to obtain a copy of my medical records from birth to age 18. I’m extremely interested in what I will find there, mostly in terms of jarring memories loose for writing purposes. I remember my doctor telling me every time I got a physical that if I kept gaining weight at this rate, next year I’d weigh X pounds. What else did my providers have to say about me?