Hello,

I work for an orthopedic surgery group. For some of them, I have to transcribe history and physicals all from handwriting, i.e., a combination of templates, patient's medical history form, and handwriting on the exam sheet from the provider and/or medical assistant. Now, this is the equivalent of me dictating the note, except that part can be skipped because I'm the transcriptionist. Is this even ethical?  I hate doing it. A former instructor told me to tell my boss it brought up risk management and medicolegal issues. I did, but she just blew me off. I know she didn't want to bring it up to the physicians because they get what that want and that's all that matters.

I just need to know what I can do to at least not have to transcribe the portion of the patient's medical history. Sometimes I just put "please see chart." What makes it worse is that the medical assistants have started signing the physicians charts, so if I have questions, they don't get answered.

Thanks
Tina Grider

Tina, this is a difficult question to answer, and I suspect that MTs are going to be encountering situations like this as well as other new documentation situations over the next few years.  If I understand the role you're describing, it sounds like you are compiling information from a variety of sources in order to create transcribed, coherent patient documentation.  Speaking as a non-lawyer/non-risk-manager, I don't necessarily see any medicolegal issue with this role provided that, once the documentation is created, a responsible physician signs off/authenticates the document.   I assume you just include in your document everything you find in these sources, because obviously MTs are not qualified to select what is important in the patient's record.  The bottom line is that what you put together as editor/compiler/transcriptionist must be authenticated by the individual legally responsible for the documentation content. 

The problem of getting feedback/confirmation from healthcare providers about unclear or possibly incorrect entries into the record is not new, of course.  Particularly in this situation where you might be dealing with illegible handwriting or otherwise unclear information, you must be able to query the responsible physician, whether by leaving blanks or other methods for queries. 

I realize this is not the role most of us trained for.  Most of us are very attached to the listen-transcribe process, and having to search through a pile of papers for information to use in creating a healthcare record is not what we're comfortable with.  But this may be one vision of the future for people with MT skills, and if we can reorient ourselves to these new roles we may ultimately find them as interesting and rewarding as traditional dictation-transcription. 

Again, if you're creating a document from templates, handwritten forms filled in by medical assistants, etc., it becomes even more important than ever to have the document authenticated by the responsible physician.  And if you can't read handwriting or have other issues with the coherence and legibility of the record, you must be able to either leave blanks in the document or query the physician or provider for clarification. 

Obviously in this situation compensation by production (per line or whatever) would not be justified.  Your understanding of healthcare documentation and your skills in sorting through the information etc. are far more important than sheer speed of transcription, and anyone doing this kind of work would need to be paid on an hourly or salaried basis. 

Incidentally, putting "please see chart" seems problematic, assuming that the purpose for having you create this record is to make it available electronically.  I assume the record you're creating is placed into an electronic form as a Word or other type of document, and anyone accessing it in that form might not have access to the paper chart.  This seems like something that may need to be worked out better with your boss and/or physicians. 

Thank you for that answer Rebecca. I guess I can feel confident about making a case for asking for a raise then:)