No tenderness
present over chest Transcribed: No tenderness
is present over the chest.Physician dictates:
Came in with chest pain Transcribed: The
patient came in with chest pain.It is also
acceptable to type all of the above as dictated.
This preserves the style of the dictator.In
my first job as a Medical Transcriptionist
in a small state run Crippled Children's
Clinic, I was instructed to type exactly
what the physician dictated. I only changed
or edited sentences such as when doctor
dictates throughout the report he or she
performed surgery on the left leg, and then
suddenly changed it over to the right leg
before the report was finished. And when
I made such a change, I carefully read previous
dictations and diagnosis of patient to be
certain which leg the doctor actually performed
surgery upon!
The Medical Transcriptionist should never
edit physician dictation aggressively. It
has to be done subtly, delicately and carefully.
You want to always strive for a favorable
response from the dictator. You need to
be involved and alert while transcribing
medical dictation so that when something
is dictated that just does not make sense,
which does not flow, or does not add up,
you will immediately detect it. Listen with
an intelligent ear to produce accurate,
intelligent, clear medical documents. Keep
in mind the fine line between "editing"
and tampering.
