Formats

2/29/96, from Steven Gulledge, sgull@teleport.com
Recently I obtained my first job as a medical transcriptionist. It's a part-time position, soon to be full-time, working in the transcription department of a 44-bed community general hospital. I've been there about about three weeks now. After just completing a two-year medical transcription program at the local community college (which utilized the SUM program) and having just made the transition into "real world" of medical transcription, of course now I've got a ton of beginner-type questions. I would really like to say "thanks in advance" to all the experienced MTs in this newsgroup who will take the time of answering, giving advice, or offering any other insight in regard to my posts here.

For now I have several questions about format. I am generally confused about the use of headings/subheadings in medical reports and exactly what type of content is appropriate for those headings. At my work, several standard macro-made templates for the various types of reports with standard headings are used by some, but not all, of the transcriptionists. The individual physicians are all quite inconsistent (as I would expect) as to what order they might choose to dictate their topics and, even more often, as to whether they dictate headings at all. There seems to be no particular departmental rules, standards, or preferences in regard to consistency in format and headings in the reports. Of course, there's some old report samples in the office procedures manual, but those are are no help...they are all inconsistent, too. When I ask my co-workers (who have been there a long time and are always very polite and otherwise helpful to me as a newcomer), the response is generally "Well, I like to do it this way, and she likes to do it that way, and I guess you pretty much have to use your own judgement." But I really feel like I need more information before I start "developing my own style" here on my new job. I realize that style and format varies widely, but before I start making too many of my own judgements as to what's acceptable or preferable, I'd like more information. For example:

At my hospital, a standard report is the "Emergency Room Report." The macro template contains two headings, "Chief Complaint" and "History of Present Illness." But some of the physicians dictate the chief complaint, and some don't. There is a chief complaint listed on the face sheet of the Emergency Room Report, entered by the nurse, which we apparently can copy to enter as the chief complaint on the transcribed report, even if the doctor doesn't mention it. Is it accepted practice to transcribe something like that when it actually was not dictated?

Is the "Chief Complaint" heading mandatory in the ER report? Most of the doctors just start dictating about the patient's illness. Some of them actually dictate the heading "History of Present Illness" first, some don't. Some just say "History" and begin. Same thing? Interchangeable? Up to me to decide? Are any of these headings mandatory, even if not dictated? Do doctors generally prefer to have headings like that provided by the transcriptionist, even if they never dictated them? Do I have to go around and ask each and every doctor how they prefer it? (I hope not!) If it were always up me, I think I'd go ahead and provide the standard headings to aid in readability and organization of the report content, but right now I'm just confused. If it's not the dictator's style to mention a particular heading, am I imposing on his style by placing one anyway?

In attempting to answer my own questions, I came up the following: from Diehl and Fordney's Medical Typing and Transcribing, "The physician may dictate the date in narrative form without topics or subtopics, or...dictate the topics and subtopics for you. You will use the proper topic as soon as reference is made to it, no matter how it is dictated." Is that really the rule? Is that what I should do all the time?

The AAMT Book of Style says we may insert obvious headings but it is not required, and information should be inserted under the proper topic when dictated out of order. This just confuses me all the more.

Usually in these ER reports, the physician continues with various topics, of course almost always with some kind of physical examination or objective findings. But if he never specifically says the heading "Physical Examination" or "Objective Findings," but instead just begins with narration, i.e., "On exam, the patient had a cut on the upper lip...," should I automatically just know to provide a heading? Or should I assume that if it wasn't dictated the physician doesn't necessarily want me to provide a heading?

How about taking it upon myself to change dictated headings somewhat for the sake of consistency among report types? For example, one physician may dictate "Laboratory" as a heading, while another may dictate "Laboratory Data," and yet another may always say "Laboratory Determinations" and yet another may say "Laboratory Work," etc. One may always dictate the heading "Assessment" while another may dictate "Impression" and another may dictate "Diagnosis." One dictates the heading "Medications" but another always says "Current Medications." One dictates the heading "Course in the Emergency Department" while another says "Course in the Emergency Room." What would be the point in using standard report templates with headings inserted if such headings are always going to be varying with the individual dictator and need to be changed (or do they?) so often? Also, how do I make the decision whether to list headings individually down the page or just put them in one long paragraph form? Or whether to list headings at all if they are not dictated?

Anyway, these are only a sampling of the formatting questions I have regarding headings. If I'm to "develop my own style" and "use my own judgement," then fine. I prefer consistency, but my concern is that I don't impose upon the dictators' style in doing so. Seems like I spend way too much time on my new job wondering whether this heading should go here or should say what or should be included. Kind of driving me a little crazy...any advice appreciated!

If you are allowed, the rules you read are right: We are to edit and organize the material, and if a diagnosis is left out and it is very obvious in the rest of the document or chart, it can be added. Most doctors leave headings to MTs. Some are sticky about it. Some departments require their set of headings, others let you go by your own style, others require you to do verbatim. I find that it is much less frustrating to be able to edit MORE rather than LESS, because then I can make the record readable and organized.

If a doctor dictates topics out of order, I hope you are allowed to put them in order. I am used to using subheadings under topics that help organize things when the doctor adds headings:

PAST MEDICAL HISTORY: The patient . . .
Surgeries:
Injuries:
Medications:
Allergies:
As to whether the physical examination and review of systems should be in paragraph form or on separate lines by subtopic, again it can be done either way unless a style is specified by your department.

I edit reports from all over the country, and all types of doctors and hospitals, so there is a tremendous variety. Even though the service has standard templates set up for each report type, there are many doctors whose dictation doesn't fit the template. The standard rule of thumb for our company is to use the important headers for each report type if at all possible. Emergency room reports generally have a chief complaint; however, it is not always used. If the doctor doesn't dictate anything that qualifies as the chief complaint, the heading is left out. In an H&P, you will generally have history of present illness, physical examination and laboratory data headings as well as impressions or admitting diagnoses at the end. Obviously for operative notes, you will almost always have preoperative diagnosis, postoperative diagnosis and procedure. Consultations may be varied. Some doctors dictate them almost like an H&P, in which case you would have similar headings; others dictate them like one big discussion, in which case there might be a history of present illness at the top and nothing else until the end where his impressions or something similar would be.

As for physical examination subheadings, different hospitals prefer different methods. We have some accounts that prefer it done in block style at the left margin with each subheading on a separate line; others don't care if it's one big paragraph. Discharge summaries are also very varied, similar to consults, but most hospitals require some sort of heading for final diagnoses or discharge diagnoses.

Most doctors that I have run across don't mind if you put the headings in, even when they don't dictate them. It does make it easier to quickly scan a report when the physical exam and lab data have a heading that is easy to find. However, I have seen some transcriptionists go overboard and try to put a heading on practically every small paragraph. That looks worse than none at all. Most also don't mind if your heading is worded a little differently.

From: Alydia Kardel, kardel@ix.netcom.com
In my experience, each physician's office is slightly different. For one account, I use the soap format abbreviated S: O: A: P:. On another account, the headings are spelled out and in bold and on this particular account each doctor's headings are different. No spaces between paragraphs to save on space. As far as abbreviating in the chart notes, each MD is unique in that as well. Some want lots of them while others want everything spelled out. In ER, abbreviations are okay except in the Assessment where everything is spelled out even if the doctor gives an abbreviation and I am sure this varies from hospital to hospital as well.

From: Prgrogers@sover.net, Mary Rogers
I do transcription for the local office of an HMO and they require no abbreviations in their transcription though the doctors seem to abbreviate everything when dictating. They publish a pamphlet for their staff listing acceptable abbreviations but I think that this lists less than one-eighth of the abbreviations used when dictating. I am able to flag any abbreviations I do not know or cannot find and usually get a note back explaining what it was. They use the SOAP format with no blank lines, and they specify if they want bold or underline.

I also transcribe for a local orthopedic practice and they seem to have a whole different set of abbreviations for their specialty. I have never had any comments from them about the use or nonuse of abbreviations but prefer to type everything out for clarity. There are very few patient records that do not have copies sent out at some point and the recipient of these copies may not be a medical professional. They use a paragraph format with blank lines between and paragraph headings such as HISTORY, PHYSICAL EXAMINATION, IMPRESSION and DISPOSITION.

In our area, format seems to depend on how things were done when the practice began. As long as a consistent format is maintained throughout the record, I think format is mostly the preference of the physicians/practice.