Retrofit
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ADT Instructions: This facility has ADT feed. If ADT screen is already filled in, you MUST verify the info and re match the ADT as well to any updated ADT that may not already appear on screen. What is dictated takes precedence over what populates, especially Work Type, Dictator, Patient Name, and MRN. If ADT screen does not auto fill, search by MRN or Billing Number in MRN or Billing #Search. If not found by MRN or Billing #, search again using patient's last name. If you cannot find a match, fill in ADT according to what is dictated. Back to Top
ADT assumption: Assumption is to be made that client has an ADT feed unless noted in the Client Profile. Back to Top
Date of Service: Populate as dictated. Date of Service is no longer a Mandatory ADT field. Date of Service field is located in the Additional fields section. If the Date of Service does not come from the ADT and/or is not dictated by the dictator, leave the Date of Service ADT definition blank. Back to Top
Dictated for ADT Optional/Additional field: The Dictated For ADT Optional field is to be used when a signing physician is dictating for another signing physician. Back to Top
Dictator: If the name appearing in the dictator field is not who is dictating or is default dictator, search for the name as it was dictated. If you cannot locate the name, click on the new button and spell the name phonetically in the appropriate fields. Back to Top
General Information: ADT definitions will transfer to the final copy of the report from the ADT screen Do not repeat it in the text screen unless specified in the client profile. Back to Top
System Dictated For: If there is a dictator that requires a dictated for, the System Dictated For field will appear underneath the Dictator Field. Populate this field as dictated. If you do not populate the field, an alert will appear to you to remind you that this field is not populated. If the dictator does not state whom they are not dictating for, send the report without the field populated. Back to Top
Abbreviations: Follow JCAHO prohibited abbreviations only. See Abbreviation List Below. Back to Top
Addendums: If dictator states he is dictating an addendum/continuation to a previously dictated report, you should: 1. Type ADDENDUM or CONTINUATION at the top of your report (regular text, not red heading); 2. Transcribe as dictated; 3. Create a QA/QC Note stating ADDENDUM or CONTINUATION. You do not need to send to QA/QC unless needed. Back to Top
Allergies: Header tag and transcribed mixed case. Back to Top
Attending at Time of Discharge: If stated, place in text where dictated, using a red header. Back to Top
Axis Format: Stacked left justified with all cap subheadings with numbers in paragraph format. Back to Top
Ballet Terms: Web site to find terms. Click Here! Back to Top
Canceled Dictation: If you are transcribing a report and the dictation suddenly ends or is canceled by the dictator, you should: 1. Verify you are at the end of the dictation by checking your audio slider. Create a QA/QC Note stating INCOMPLETE OR CANCELED; 2. Upload the job; you do not need to route to QA/QC (via QA Marker) unless there are other issues with the report. Back to Top
Cardinal Numbers: Are to be used if dictated, as long as there is not a year stated afterwards. Back to Top
Carbon Copies: As dictated by dictator. Back to Top
Close ADT Screen: Alternate C. Back to Top
Consultations: For consultations the client has specifically instructed us not to change the work type to letter, even if the dictator says he's dictating a consult in the form of a letter. We should transcribe as dictated, leaving the work type as consultation. Of note, the address and body headings should not be added; there are no standard headings (Control S) in a consultation that is dictated as a letter. Back to Top
Continuations: If dictator states he is dictating an addendum/continuation to a previously dictated report, you should: 1. Type ADDENDUM or CONTINUATION at the top of your report (regular text, not red heading); 2. Transcribe as dictated; 3. Create a QA/QC Note stating ADDENDUM or CONTINUATION. You do not need to send to QA/QC unless needed. Back to Top
Courtesy Copies: Only as dictated. If cc name is not understood and phonetic spelling not possible, create "new" entry and put "Dr.____" in last name field. Leave QA/QC Note. If last name only is given and you cannot choose between multiple entries in the database, create a "new' entry and put Dr. and doctor's name in the last field (Ex: Dr. Jones), Leave QA/QC Note. Back to Top
Date Format: (Short Date) mm/dd/yyyy; (Long Date) month dd, yyyy for letters when requested to transcribe in the text. Incomplete date dictated – Enter as dictated. Back to Top
Department Names and Clinic Names: No longer capitalized, unless they are specific to an institution; e.g. John Smith Medical Center Endocrinology Clinic. Follow AAMT-BOS2 guidelines regarding these. Back to Top
Diagnosis: Diagnosis should be written out - Not abbreviated - in the Impression, Assessment, and Diagnosis sections of a report. The Summary can have abbreviated diagnosis in it. Back to Top
If a dictator is in the database as an attending and says he is dictating for another attending, create a red letter heading for </ATTENDING PHYSICIAN/> and add it to the report.
If you feel the dictator is mistakenly identified as an attending in our database, do not put the attending's name anywhere on the report or in the ADT. Create a QA note stating the name of the attending given by the dictator and send an E-mail to your supervisor with the Internal Job Number of the report. In the subject line place, "(Name of Facility) Dictator Error in Database." Back to Top
Doctor's Name: Note that you are no longer to put an underscore if you do not understand or cannot reference a doctor's name. You should now treat this like any other blank and put a QA marker. Back to Top
Fail Field is no longer used. A QA note is now the way a report is failed. Back to Top
Follow up: Two words - follow up - is always the verb form of the word. For a noun or an adjective, either followup or follow-up is correct. Back to Top
Gram-positive versus Gram Stain: Correct capitalization is Gram stain; gram-positive. Back to Top
Headings: Red Headings should be used throughout, if headings are dictated, even in letter work types. Formatting is done on the back end to convert the headings to the customer's specifications. This standardizes how you will transcribe all Retrofit reports. If headings are not dictated, transcribe in sentence format. Back to Top
Incomplete Dictation: If you are transcribing a report and the dictation suddenly ends or is canceled by the dictator, you should: 1. Verify you are at the end of the dictation by checking your audio slider. Create a QA/QC Note stating INCOMPLETE OR CANCELED; 2. Upload the job; you do not need to route to QA/QC (via QA Marker) unless there are other issues with the report. Back to Top
Incorrect work type entered by dictator: If the incorrect work type is entered by the dictator, change the work type to the appropriate work type unless noted in the client profile differently. Back to Top
Lengthy Expansions: Lengthy expansions are not recommended. Certain clients prohibit their use. Back to Top
Letter Format Protocol: A Standard Letter format will be as follows: Back to Top
1. Letter Standard that is Mandatory for WT inclusive of an </ADDRESS/> and </BODY/> tag
2. Date will be populated from Date of Service and/or Date of dictation. It will not be required to be transcribed.
3. Closing -- Do NOT type. It will be populated from the template.
4. If a dictator requests the letter to go to multiple doctors, send the letter to one doctor and place the rest in carbon copies.
5. Exceptions on work type Consultations -- See Consultations above
Mrs., Ms., Miss, Mr.: Use Mrs or Miss if known; Miss if not known. According to the AAMT-BOS2, transcription is going away from using a period after prefixes on names. Back to Top
No Dictation: If there is no dictation for a report, you should: 1. Verify you are at the end of the dictation by checking your audio slider; 2. CHANGE the work type to 999 No Dictation. Back to Top
Numbered Lists: Create numbered list, flush left. Numeral, period and space twice after the period; do not tab or indent. Do not double space. Back to Top
Numbers
and Roman Numerals: Numerals, or figures, stand out from the surrounding
text and serve a functional purpose in medical reports, where they should be
used almost exclusively as opposed to spelled-out numbers. There is a trend away from the use of roman numerals
and toward the use of arabic numerals. A good example of this is in diabetes
terminology, where an international expert committee dropped the roman numerals
in favor of arabic, noting the danger of a roman numeral II being misread as an
arabic number 11. In addition, the AMA Manual of Style states, "Avoid the
use of roman numerals except when part of established nomenclature." Most
numerals used in medicine are expressed as arabic numerals. Therefore, a general
rule is to use arabic numerals unless roman numerals are specified or unless
there is strong documentation that the preferred form is roman. Grades are
generally written in arabic numerals:
grade 3/6 holocystolic murmur; grade 3 chondromalacia patellae.
Number examples:
Use numerals rather than spelled out on ages.
Exceptions:
Beginning of sentences: numbers should be spelled out.
Decades: Use numeral followed by a small "s" to designate decades. Do not use an apostrophe
Standard bipolar leads: Use roman numerals. lead I, lead II, lead III. Back to Top
Patient Name in Text: Populate when dictated from ADT. If no ADT match, spell phonetically. Back to Top
Physical Examination Format: Paragraph format with all caps subheadings, if a subheading is dictated within the Physical Examination. If subheadings are not dictated, type in sentence format. Example: HEENT: Negative. NECK: Supple. LUNGS: Clear to auscultation and percussion. On heart exam, the patient is in sinus rhythm. The abdomen is soft without masses. Back to Top
Physician Name in Text: Populate when dictated from database, using header tags as necessary. If not in database, insert QA marker. Back to Top
PO: p.o. is acceptable in the text. Back to Top
Report Title Format: Report Title heading would be used if a dictator specifies that a specific title should be placed at the top of the report. Header Tag of </REPORT TITLE/> and as dictated. Back to Top
Review of Systems Format: Paragraph format with all caps subheadings, if a subheading is dictated within the Review of Systems. If subheadings are not dictated, type in sentence format. Example: ENDOCRINE: Diabetes mellitus. RESPIRATORY: Negative. The patient has congestive heart failure. No neurological complaints are reported. Back to Top
Spacing: Two spaces after colons and periods. Back to Top
Unqualified Work Type: Change the Work Type to proper Type and click on Break. Back to Top
Using X in Text: Place an X in place of the "times" when the word "times" is dictated and means the number of times a thing is done. An X should only be used before a number; not afterwards; i.e., x2, versus 2 times. Back to Top
</ADDRESS/>
Person to whom the letter is going to with their address.</BODY/>
REASON FOR REFERRAL: Irregular heartbeats. (If the dictator states something like this before she/he begins her/his letter, place it in this location)Dear Dr. Smith,
I had the pleasure of seeing Jane Doe today in the cardiology clinic. She is a 29-year-old female who presents with irregular heartbeat. She has no past history of heart problems.
</PAST MEDICAL HISTORY/>
The patient has a history of peptic ulcer disease, but is otherwise in good health. She is gravida 3, para 2.In regard to social history, the patient is a nonsmoker and drinks socially.
</REVIEW OF SYSTEMS/>
Otherwise, negative.</PHYSICAL EXAMINATION/>
VITAL SIGNS: Normal. HEENT: Negative. The heart is in regular sinus rhythm. ABDOMEN: No masses.My impression is that Miss Doe is suffering from stress-related irregular heart rhythm, likely due to the hectic schedule she maintains.
</RECOMMENDATIONS/>
1. Deep breathing exercises.
2. Tylenol p.r.n. headaches.Thank you for the opportunity to participate in Miss Doe's care. If you have any further questions, please let me know.