When to use a.m., AM; p.m., PM ?
Acceptable abbreviations for ante meridiem(before noon) and post meridiem(after
noon), with the lowercase forms being preferred. Formal publications use small capitals, which, if available, may also be used in transcription.
8:15 a.m. or 8:15 AM or 8:15..AM
Do not use these abbreviations with a phrase such as in the morning, in the evening, tonight, o’clock.
8:15 a.m. not 8:15 a.m. o’clock
10:30 PM not 10:30 PM in the evening
Use periods with a.m. and p.m. so that a.m. won’t be misread as the word am.
Do not use periods with the uppercase AM and PM.
Insert a space between the numerals preceding these abbreviations and the abbreviations themselves, but do not use spaces within the abbreviations.
11 a.m. or 11 AM not 11a.m. or 11AM not 11 a. m. or 11 A M
Tuesday, July 17, 2007
Monday, June 18, 2007
Date Dictated and Date Transcribed
Date Dictated and Date Transcribed
These dates should be recorded to monitor dictation and transcription patterns as well as to provide documentation of when the work (dictation or transcription) was done. Some dictation and transcription systems are specially designed to automatically record these dates.
Health care reports are, among other things, legal documents. As part of risk management, dictation and transcription dates should be entered accurately and should not be altered.
Capitalize D and T and follow each by a colon and appropriate date, using numerals separated by virgules or hyphens.
Some facilities prefer to use six-digit dates and others, eight-digit. All these styles are acceptable.
D: 4/18/00
T: 4/19/00
D: 04-18-00
T: 04-19-00
D: 04/18/2000
T: 04/19/2000
Note: ASTM’s E2184, Standard Specification for Healthcare Document Formats calls for identification of the place of dictation as well.
When the month, day, and year are given in this sequence, set off the year by commas. Do not use ordinals.
She was admitted on December 14, 2001, and discharged on January 4, 2002. not ...January 4th, 2002 (4th is an ordinal)
Do not use commas when the month and year are given without the day,
or when the military date sequence (day, month, year) is used.
She was admitted in December 2001 and discharged in January 2002.
She was admitted on 14 December 2001 and discharged on 4 January 2002.
These dates should be recorded to monitor dictation and transcription patterns as well as to provide documentation of when the work (dictation or transcription) was done. Some dictation and transcription systems are specially designed to automatically record these dates.
Health care reports are, among other things, legal documents. As part of risk management, dictation and transcription dates should be entered accurately and should not be altered.
Capitalize D and T and follow each by a colon and appropriate date, using numerals separated by virgules or hyphens.
Some facilities prefer to use six-digit dates and others, eight-digit. All these styles are acceptable.
D: 4/18/00
T: 4/19/00
D: 04-18-00
T: 04-19-00
D: 04/18/2000
T: 04/19/2000
Note: ASTM’s E2184, Standard Specification for Healthcare Document Formats calls for identification of the place of dictation as well.
When the month, day, and year are given in this sequence, set off the year by commas. Do not use ordinals.
She was admitted on December 14, 2001, and discharged on January 4, 2002. not ...January 4th, 2002 (4th is an ordinal)
Do not use commas when the month and year are given without the day,
or when the military date sequence (day, month, year) is used.
She was admitted in December 2001 and discharged in January 2002.
She was admitted on 14 December 2001 and discharged on 4 January 2002.
Wednesday, April 18, 2007
Best way to handling corrections revision of the Patient Record
The rules to modifying the Patient Record should be strong foundation for the enterprise seeking to develop policies and procedures. In order to ensure the admissibility of the medical record as evidence, the enterprise must first establish policies and procedures that address
• Author authentication
• Medical record access control
• Medical record archiving and retention
• Medical record security
• Medical record disaster recovery policies and procedures
By establishing controls over the creation of medical records, enterprises can ensure the nonrepudiation of corrections, revisions, additions, and addenda made in the normal course of business.
Ultimately, by controlling the how, who, where, and when of creating the medical record, the enterprise establishes the methodology for performing valid corrections, revisions, additions, and addenda.
The best practices of a healthcare enterprise can develop an effective and valid policy and procedure for the correction, revision, addition, and addenda of health information contained within the medical record.
The key characteristics of an effective policy and procedure include
• Author authentication and accountability
• Clear indication of correction or amendment date and time
• Policies and procedures that prevent unauthorized alteration of documents
• Clear delineation of parent document
• Clear delineation of corrected or amended document
• Notification of health information recipients when amendments and corrections occur
• Retention of the parent document for historical reference
Though it is true that no single rule that addresses medical record correction and amendment exists, enough guidance is available to allow healthcare providers to develop a workable policy and procedure to address the creation of valid medical record corrections and amendments.
• Author authentication
• Medical record access control
• Medical record archiving and retention
• Medical record security
• Medical record disaster recovery policies and procedures
By establishing controls over the creation of medical records, enterprises can ensure the nonrepudiation of corrections, revisions, additions, and addenda made in the normal course of business.
Ultimately, by controlling the how, who, where, and when of creating the medical record, the enterprise establishes the methodology for performing valid corrections, revisions, additions, and addenda.
The best practices of a healthcare enterprise can develop an effective and valid policy and procedure for the correction, revision, addition, and addenda of health information contained within the medical record.
The key characteristics of an effective policy and procedure include
• Author authentication and accountability
• Clear indication of correction or amendment date and time
• Policies and procedures that prevent unauthorized alteration of documents
• Clear delineation of parent document
• Clear delineation of corrected or amended document
• Notification of health information recipients when amendments and corrections occur
• Retention of the parent document for historical reference
Though it is true that no single rule that addresses medical record correction and amendment exists, enough guidance is available to allow healthcare providers to develop a workable policy and procedure to address the creation of valid medical record corrections and amendments.
Tuesday, January 2, 2007
Medical Transcription salaries in India
It’s no wonder that a career in medical transcription can lead to a good salary.
In India Medical Transcription Companies calculate a medical transcriptionist salary using different methods. Either medical transcriptionist are paid on per line basis or on monthly basis. Some company have fixed and variable both component as part of salary.
Before you can decide if this career is right for you, it’s a good idea to become familiar with the job duties associated with medical transcription. In a nutshell, medical transcription is the process of converting a doctor’s notes or audio recordings into a written document. This document is then used for insurance purposes and stored with the patient’s records. A medical transcription expert ensures that all regulatory and insurance industry requirements are fulfilled. These duties can be performed either on-site at a hospital, or from an off-site work location. Many people in the medical transcription field are able to work from home.
A Career in Medical Transcription Offers a Good Salary
Depending on experience, a medical transcription salary offers between Rs 7k and Rs 35k per month. In today’s job market, this isn’t a bad rate for a career that takes minimal training. With a two-year associates degree, you can quickly become a member of the medical transcription workforce.
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