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    • Join Date: Oct 2007
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    #1

    Is this sentence okay?

    I am a medical transcriptionist, and this is the way the doctor dictated this.

    His thyroid drawn in September of 2007 is normal

    or His thyroid drawn in September of 2007 was normal.

    Which one is correct?


    Erin

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    #2

    Re: Is this sentence okay?

    Quote Originally Posted by erempa View Post
    I am a medical transcriptionist, and this is the way the doctor dictated this.

    His thyroid drawn in September of 2007 is normal

    or His thyroid drawn in September of 2007 was normal.

    Which one is correct?


    Erin
    Why don't you just type it as it was dictated?


    • Join Date: Sep 2007
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    #3

    Re: Is this sentence okay?

    Quote Originally Posted by 2006 View Post
    Why don't you just type it as it was dictated?
    Unfortunately that is not her job.

    This is a quote the following website:

    Medical Transcriptionists

    Doctors get a lot of flack for their sloppy handwriting. E's that look like B's or Q's that look like G's, can completely transform a handwritten prescription, diagnosis, or instruction from one meaning into another. And in the world of medicine, where a doctor's prescription, diagnosis, and instructions must be precise, that can be downright dangerous. Luckily, medical transcriptionists exist. They convert a doctor's quickly scrawled and barely decipherable written note into a clear, readable medical record or transcribe the notes that doctors dictate into voice recorders. Usually they do both on a computer, so they need a good working knowledge of computers in general and word processing in particular.
    Since the information in medical records is critical to patient care, it's essential that this transcription be absolutely perfect. But neither handwriting nor dictation are always completely clear, and in the medical field, many words that sound more or less the same and may even be similarly spelled have very different meanings. Sometimes even a difference of a single letter can completely change the meaning of a medical term or the name of a drug. Consequently, medical transcriptionists spend some of their time researching unfamiliar words in medical reference materials making sure they’ve translated the word they think they’ve heard into the one the physician actually dictated. They are also responsible for grammar and clarity.
    I can see this to be difficult at times. But some things this person is asking us seem to be rather trivial (past and present verb tenses for example)

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    #4

    Re: Is this sentence okay?

    Quote Originally Posted by Naamplao View Post
    Unfortunately that is not her job.

    I can see this to be difficult at times. But some things this person is asking us seem to be rather trivial (past and present verb tenses for example)
    I really think it is her job to put on paper what has been dictated, as it was dictated. If she has a serious issue, she can ask the physician to clarify. And I agree that a lot of her questions are quite trivial.


    • Join Date: Sep 2007
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    #5

    Re: Is this sentence okay?

    Quote Originally Posted by 2006 View Post
    I really think it is her job to put on paper what has been dictated, as it was dictated. If she has a serious issue, she can ask the physician to clarify. And I agree that a lot of her questions are quite trivial.
    Well I thought so too at first, but when I did some investigation I found out that it is their job to make these scribbles/dictations readable. To me this is a difficult job since you can easily make a mistake with a bad rewrite of a doctor's messages. I can imagine that your career as a Medical Transcriptionist would be rather short if you constantly went back to a doctor for clarification or copied his bad grammar.

    Having said that though, the questions we are getting are not difficult for someone who elected this career.


    • Join Date: Nov 2007
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    #6

    Re: Is this sentence okay?

    Having worked 35 years of my life in hospitals, reading patient notes and other doctor's reports, I can see you might be a little anxious about the tense, if you are unsure if suddenly you have changed the meaning. Rest assured, the meanings are the same, it is the 'perspective' of the doctor dictating the report that has changed.
    "...was normal" : When the patient's thyroid functioning was tested in September, it was normal.

    Now imagine the doctor going over the pathology reports as he writes his discharge summary, and is thinking to himself along the lines, "I see from the pathology report that a blood test was done last September, and this indicates that his thyroid is functioning normally. We wouldn't anticipate that this would change over the short space of time since then, so we can presume the thyroid is continuing to function normally." This comes out of his mouth and into the dictaphone as, "His thyroid as drawn last September (= as shown from the blood drawn and tested in September) is normal."

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