MedQuist DocQscribe Standards and Guidelines

Also Known As MedQuist DocQscribe Guidelines

Version 3.0

GENERAL INFORMATION ___________________________________________________________________ 4 

PROHIBITED ABBREVIATIONS AND SPECIAL CHARACTERS __________________________________ 5 

PROHIBITED ABBREVIATIONS _________________________________________________________________ 5 _________________________________________________________________________ _________ 5 SPECIAL CHARACTERS ______________________________________________________________________ 5 

CLIENT OVERVIEW _________________________________________________________________________ 6 

REFERENCES ______________________________________________________________________________ 6 REPORT FORMAT ___________________________________________________________________________ 6 REVIEW OF SYSTEMS FORMAT ________________________________________________________________ 6 PHYSICAL EXAMINATION FORMAT ______________________________________________________________ 6 NUMBERED LISTS AND SUB LISTS FORMAT ______________________________________________________ 7 PATIENT NAME IN THE TEXT OF REPORT _________________________________________________________ 7 QA-ON-DEMAND PROTOCOL (DIRECT SUBMISSION TO QA) _________________________________________ 7 QA MARKER PROTOCOL (DIRECT SUBMISSION TO CUSTOMER) ______________________________________ 7 QA/QC NOTE PROTOCOL - TRANSCRIPTION _____________________________________________________ 7 DATE FORMAT _____________________________________________________________________________ 8 ALLERGIES ________________________________________________________________________________ 8 PHYSICIAN NAMES IN THE TEXT OF A REPORT ____________________________________________________ 9 FACILITIES/LOCATIONS IN THE TEXT OF A REPORT ________________________________________________ 9 PHYSICIAN ADT DEMOGRAPHIC VS. HEADING TAG CLARIFICATION ___________________________________ 9 REPORT TITLE FORMAT ______________________________________________________________________ 9 

ADT INSTRUCTIONS _______________________________________________________________________ 10 

GENERAL ADT INFORMATION ________________________________________________________________ 10 DEMOGRAPHICS AND ADT SCREEN INFORMATION _______________________________________________ 10 ADT DEMOGRAPHIC INFORMATION - CLARIFICATION OF EACH FIELD _________________________________ 10 DEMOGRAPHIC SECTION (TOP LEFT SECTION) _______________________________________________ 10 WORK TYPE SECTION (MIDDLE LEFT SECTION) _______________________________________________ 10 WORK TYPE ______________________________________________________________________________ 10 DICTATOR SECTION (BOTTOM LEFT SECTION) ________________________________________________ 11 DICTATOR ________________________________________________________________________________ 11 DICTATED FOR ____________________________________________________________________________ 11 MANDATORY ADT SECTION (TOP RIGHT SECTION) ____________________________________________ 12 MANDATORY ADT FIELDS ___________________________________________________________________ 12 ADDITIONAL ADT SECTION (BOTTOM RIGHT SECTION) _________________________________________ 12 OPTIONAL ADT FIELDS _____________________________________________________________________ 12 ADT MATCHING ___________________________________________________________________________ 12 DICTATED FOR ADT ADDITIONAL FIELD (LOCATED UNDERNEATH MANDATORY ADT DEMOGRAPHIC FIELDS) _ 12 DATE OF SERVICE _________________________________________________________________________ 12 PHYSICIAN FIELDS _________________________________________________________________________ 13 AVAILABLE NAMES DATABASE _______________________________________________________________ 13 SEARCHING ______________________________________________________________________________ 13 VIEW OPTION _____________________________________________________________________________ 13 NEW CONTACT OPTION _____________________________________________________________________ 13 

INCOMPLETE DICTATION INSTRUCTIONS __________________________________________________ 14 

INCOMPLETE OR CANCELED DICTATIONS ________________________________________________ 14 NO DICTATION __________________________________________________________________________ 14 ADDENDUM/CONTINUATION _____________________________________________________________ 14 

QA/MME INSTRUCTIONS ___________________________________________________________________ 15 

QA MARKER PROTOCOL ____________________________________________________________________ 15 QA/QC NOTE PROTOCOL ___________________________________________________________________ 15 

WORK TYPE SPECIFIC INSTRUCTIONS _____________________________________________________ 16 

LETTER FORMAT PROTOCOL _________________________________________________________________ 16 

DICTATOR SPECIFIC INSTRUCTIONS _______________________________________________________ 17 2

PHYSICIAN NOMENCLATURE ______________________________________________________________ 18 

APPENDIX ________________________________________________________________________________ 20 

DEMOGRAPHICS AND ADT SCREEN INFORMATION _______________________________________________ 20 ADT DEMOGRAPHIC INFORMATION - CLARIFICATION OF EACH FIELD _________________________________ 20 DEMOGRAPHIC SECTION (TOP LEFT SECTION) _______________________________________________ 20 AVAILABLE NAMES DATABASE (CONTROL N) ___________________________________________________ 21 SEARCHING ______________________________________________________________________________ 21 

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General Information This document details MedQuist's standards for producing transcribed documents in DocQscribe. These standards have been developed with the intent of simplifying the process and gaining efficiency while creating high-quality medical reports. DocQmanage Client Profiles will list the EXCEPTIONS or, in some cases, preferences of the individual client. Therefore, the Client Profile supersedes those applicable sections of this document. These guidelines should be used on 100% of MedQuist clients as a baseline with individual Client Profiles acting as a supplement to this document. Any questions or concerns about the content of this document or how to apply these standards while transcribing in DocQscribe should be sent to mtquestions@medquist.com.

Note: Any previous MedQuist guidelines are obsolete outside of this document.

Note: Any text used in examples is for ease of ready only.

Terminology Reference Library Term Also known as: headings/heading tag header tags, heading tags, XML tags, red header tags,

red heading tags body of document

DocQscribe Output, DQS Output, edit screen, blank screen, text screen.

@@ code

Stop codes, jump codes, @@ signs, stop points.

MedQuist DocQscribe Standards and Guidelines

DQS Guidelines, MedQuist DQS Guidelines, MedQuist best practices for transcription

Demographics Screen ADT screen, Ctrl + D ADT demographics ADT, demographics, ADT definition, ADT field,

demographic field, Ctrl + D field Available Names database physicians database, dictator database

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Prohibited Abbreviations and Special Characters Prohibited Abbreviations Below is The Joint Commission (TJC -- previously JCAHO) Official Do Not Use List., The below list is the MedQuist standard for prohibited abbreviations. _________________________________________________________________________

Note: If a client requires additional prohibited abbreviations, or has their own list, specifics will be noted in the client profile. Any previous MedQuist style guides, abbreviations lists, etc., are obsolete outside of this document and the client profile (including BOS2 Dangerous Abbreviations). __________________________________________________________________________

Special Characters -The following special characters are prohibited from being utilized in DocQscribe:

& subscripts

superscripts @.

degree sign \ ~ ^ |

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Client Overview References MedQuist DocQscribe Standards and Guidelines Client Profile MedQuist National Quality Program AAMT Book of Style for Medical Transcription, Second Edition (AAMT is now known as AHDI) Report Format Transcribe as dictated correcting only for grammar and client's format preferences.

Review of Systems Format Per the client profile, format the Review of Systems based upon the following examples: OPTION 1 - Paragraph format with all cap subheadings </REVIEW OF SYSTEMS/> NEUROLOGICAL: Patient denies blackout spells, seizures, weakness/paralysis, tremor/handshaking, difficult concentration… RESPIRATORY/ALLERGIC: Patient denies chronic cough,…. HEAD, NECK AND EYES: Patient denies dry mouth, chronic sore throats, …. DERMATOLOGICAL: Denies rashes, skin lesions, ... HEMATOLOGIC: Denies previous transfusions…. GASTROINTESTINAL: Denies constipation, diarrhea, …. CARDIOVASCULAR: Denies …. OPTION 2 - Stacked left justified with all cap subheadings </REVIEW OF SYSTEMS/> NEUROLOGICAL: Patient denies blackout spells, seizures, weakness/paralysis, tremor/handshaking, difficult concentration, …. RESPIRATORY/ALLERGIC: Patient denies chronic cough …. HEAD, NECK AND EYES: Patient denies dry mouth, chronic sore throats, …. DERMATOLOGICAL: Denies rashes, skin lesions, ... HEMATOLOGIC: Denies previous transfusions…. GASTROINTESTINAL: Denies constipation, diarrhea, …. CARDIOVASCULAR: Denies ….

Physical Examination Format Per the client profile, format the Physical Examination based upon the following examples: OPTION 1 - Paragraph format with all cap subheadings </PHYSICAL EXAMINATION/> GENERAL: A well-developed and well-nourished patient…. HEAD: No abnormalities…. NECK: Supple with no lymphadenopathy …. CHEST: Clear to auscultation with normal chest excursion. HEART: Regular in rate and rhythm. ABDOMEN: Soft, nondistended and nontender…. EXTREMITIES: No clubbing, cyanosis or edema. OPTON 2 - Stacked left justified with all cap subheadings </PHYSICAL EXAMINATION/> GENERAL: A well-developed and well-nourished patient…. HEAD: No abnormalities…. NECK: Supple with no lymphadenopathy …. CHEST: Clear to auscultation with normal chest excursion. HEART: Regular in rate and rhythm. ABDOMEN: Soft, nondistended and nontender… EXTREMITIES: No clubbing, cyanosis or edema.

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Numbered Lists and Sub lists Format Create the numbered list flush left by typing the numeral, period, two spaces, and then the text. Do not use tab or indent. Do not insert blank lines between numbered items. Sub lists (letters) are only to be incorporated if dictated. Use paragraph form unless dictator indicates a list format (i.e., numbers or states “next” or “new line”). Always number a list, unless profile states otherwise. Do not number just one item. Numbered List Example </RECOMMENDATIONS/> 1. Schedule a follow-up visit with primary care physician in 2 weeks. 2. Continue with medications as noted in the chart. 3. Continue with physical therapy as discussed and shown. Sub List Example </RECOMMENDATIONS/> 1. Schedule a follow-up visit with primary care physician in 2 weeks. a. Text. b. Text. 2. Continue with medications as noted in the chart. 3. Continue with physical therapy as discussed and shown.

Patient name in the text of report No patient names in the text. Transcribe “the patient” or grammatically correct variation instead (e.g., The patient was seen… or "Patient seen on… or The patient’s last visit was… or Patient's mother states).

QA-on-Demand Protocol (Direct Submission to QA) If you deem the document insufficient to meet the quality standard, leave all QA marker(s) and check the QA check box at the completion of your report to submit the document to QA. Additional information can be entered into the QA/QC Note.

QA Marker Protocol (Direct Submission to Customer) If the document is deemed sufficient and meets MedQuist quality standards, leave the QA Marker in the text of the document and do not check the QA box upon upload as well as following the QA/QC Note Protocol as noted below.

QA/QC Note Protocol - Transcription The client can view and/or print QA/QC Notes. Therefore, keep comments professional (no derogatory remarks), brief, and issue-oriented, such as "advise on spelling.” Key Reasons to use the QA/QC Note for MTs

- Addendum/Continuation. - Incomplete Dictation. - Discrepancy in the report (Replace all discrepant text with QA Markers and insert QA/QC Note

describing the discrepancy - Ex. Dictated right hand under history, left hand under impression.). - Courtesy copies that are unintelligible (refer to Courtesy Copy section for specifics). - Blanks in reports - Additional info, report specific (when needed) to assist QA in addressing a QA marker when

requested to go to QA on demand. Expansions DocQscribe expansions should be limited to 1,000 characters per expansion. Lengthy expansions are not recommended. Do not include standards in personal expansions because updates will be missed, DocQscribe allows users to create an abbreviation in the expansion file which links to the desired standard. See DocQscribe User Help Guide in DocQscribe. NOTE: Using an expansion does not release the MT from matching the transcription to the dictation. Use with caution.

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Courtesy or Carbon Copies - Only as dictated. - Select from the available names list to populate. - If CC name is clearly dictated but not found in CC list, create "new" entry and enter information

in the appropriate fields. Any dictated fax numbers should be entered in the last name field after the name: "Smith, 555-1222"

- If CC name is not understood and phonetic spelling not possible, create "new" entry and put

"Dr.____" using 10 underscores, in last name field. Ensure QA/QC Note states "cc unintelligible". - If CC stated as “Dr. John Smith” do not assume MD. Enter First Name as “Dr. John” and Last

Name as “Smith.” - If last name only is given and not in database, or you cannot choose between multiple entries in

the database, create a "new” entry. Enter as Last Name: Dr. Smith. Date Format In body of document, transcribe dates as dictated inserting appropriate punctuation and use ordinals where appropriate.

Short Form: 09/02/2008 Long Form: September 2, 2008 Ordinals: the 2nd of September 2008 Military Style: 2 September 2008 Incomplete Date: 09/2008 or September 2008 (when month year only are dictated)

9/2 or September 2 or September 2nd (when month day only are dictated)

Spacing

- Insert 2 spaces after a colon. - Insert 2 spaces after periods that end sentences. - Insert 2 hard returns (Enter key) between paragraphs (one at the end of the sentence and an

extra return to create 1 blank line between paragraphs). - Insert 1 space before and/or after a dash (does not apply to hyphens).

Allergies Heading and transcribed mixed case. </ALLERGIES/> Patient had no known allergies. Then begin the next section with red-tagged heading to terminate ALLERGIES special formatting.

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Axis Format Stacked, left justified with mixed case subheadings, using roman numerals. </DIAGNOSES/> Axis I: Major depressive disorder, single episode, severe, without psychotic features. Alcohol abuse. Axis II: Dependent personality disorder. Axis III: Text. Axis IV: Text. Axis V: Text. Standards Protocol All heading tags included in a standard are to remain in the body of the document even if not dictated. If there is nothing dictated for a specific heading, remove the @@ code only. Insert and utilize any standard as directed by dictator. Mandatory standards will be noted in either the work type specific instructions section or dictator specific instructions section of the client profile. Physician Names in the Text of a Report Phonetics are acceptable only if not found in physician database or facility web site or other reliable data source unless noted in the client profile. Facilities/Locations in the Text of a Report Phonetics are acceptable only if not found in physician database, facility web site or other reliable data source unless noted in the client profile. Physician ADT Demographic vs. Heading Tag Clarification Work Type Classification Physician Clarification Operative Report Surgeon: Will populate from Dictator/Dictated For. Do not

transcribe. Any alternatives will be noted in the client profile Assistant: Transcribe as dictated using </ASSISTANT/> heading tag. If more than one assistant, use </ASSISTANTS/> heading tag and transcribe all names stacked left justified. Any alternatives will be noted in the client profile.

Consultation

Consultant: Will populate from Dictator/Dictated For. Do not transcribe. Any alternatives will be noted in the client profile. Referring Physician: Will populate from the Referring Physician field. Do not transcribe. Any alternatives will be noted in the client profile.

All Other

Physician Fields: Search for the Physician title dictated in the ADT demographic fields and populate as dictated. If physician field is not located on the ADT demographic screen, transcribe in the body of the report the heading tag identifying the physician that was dictated followed by the name. (i.e. - Co-Surgeon was dictated on an Operative Report. There is not a Co-Surgeon ADT demographic field. use </CO-SURGEON/> heading tag then populate name as dictated) Any alternatives will be noted in the client profile.

Report Title Format If a customer requires a </REPORT TITLE/> to be used, there will be a mandatory WT standard or noted in the client profile. The title only should be noted under the heading; additional verbiage, if dictated, must be placed under a new, appropriate red heading to terminate special formatting. Ex: </REPORT TITLE/> Cardiology Consultation (no period here) </REASON FOR CONSULTATION/> I was asked by Dr. Smith to see this patient regarding onset of chest pain.

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ADT Instructions General ADT Information Information entered into the Demographics and ADT screen will transfer to the final copy of the report. Do not retype in the body of document unless specified in the client profile. Demographics and ADT Screen Information

ADT Demographic Information - Clarification of each field DEMOGRAPHIC SECTION (top left section) All information in this section is generated by dictator entry at time of dictation or internal DEP processes. These fields should never be altered. The Date/Time dictated will always appear in Eastern Time Zone.

Note: Please see the Appendix Section of this document for further detailed information

WORK TYPE SECTION (middle left section) Work Type This field populates with the work type name that is entered by the dictator at time of dictation. If incorrect work type is entered by dictator, change to the appropriate work type based on the information dictated. Always check the client profile for work type specific instructions.

- Sort by Name: Sorts alphabetically by the work type name - Sort by Number: Sorts numerically by the work type number

Scenario 1 - Work Type entered by dictator matches information being dictated

-Leave work type as populated Scenario 2 - Work Type entered does not match information being dictated and is a work type you transcribe

-Change to work type that matches information being dictated. Transcribe as dictated following work type guidelines.

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Scenario 3 - Work Type entered does not match information being dictated and is not a work type you transcribe.

-Change to the work type that matches information being dictated. From the DocQscribe edit screen choose Break in the upper right hand corner. Breaking the job in this manner will save the work type change and route the job appropriately.

Scenario 4 - Work Type comes in as Zinvalid and correct work type is available in work type list

-Change to work type that matches information being dictated. Transcribe as dictated following work type guidelines or refer to scenario 3 above to break job for rerouting if you do not transcribe this work type.

Scenario 5 - Work Type comes in as Zinvalid and correct work type is not available in work type list or cannot be determined based on information dictated

-Leave work type as populated and transcribe as dictated. Enter a QA/QC Note stating "Work Type Dictated (WT Name) Not Found"

Scenario 6 - Work Type entered does not match information being dictated and is not in the work type list

-Leave work type as populated and transcribe as dictated. Enter a QA/QC Note stating "Work Type Dictated (WT Name) Not Found"

Scenario 7 - No Dictation Work Type:

-Please refer to the No Dictation Work Type instructions within this document. DICTATOR SECTION (bottom left section) Dictator The Dictator demographic field populates with name associated with the access code entered at the time of dictation. Scenario 1 - Dictator in the ADT screen matches the name of the person dictating the job

-Leave dictator as populated. Scenario 2 - Dictator in the ADT screen (Named, Default Dictator or Generic ID) does not match the name of the person dictating the job and name of person is found in database.

--Select name of person dictating from the database. Scenario 3 - Dictator in the ADT screen (Named, Default Dictator or Generic ID) does not match the name of the person dictating the job and name of person is not found in database.

1. Click on New at database search screen. 2. Spell the name phonetically.

Scenario 4 - Dictator in ADT screen is Default Dictator or Generic ID and the name of the dictator is not stated.

1. Click on Name>New. 2. Populate the New contact as follows:

Last Name: UNKNOWN First Name DICTATOR

Dictated For The Dictated For field will appear when the dictator is required by the facility to have someone else sign the report with or for the dictator. Populate this field as dictated. If you do not populate the field, an alert will appear reminding you that this field is not populated. If the dictator does not state whom he/she is dictating for, send the report without the field populated. Example: Resident physician dictating for their Attending physician - in this case, the resident would be the dictator and their attending would be the dictated for. Dictator may state this as "This is Dr. Smith dictating for Dr. Jones" or "This is Dr. Smith. Attending is Dr. Jones."

Note: This is the most common practice, especially in a teaching facility.

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MANDATORY ADT SECTION (top right section) Mandatory ADT fields Fields will populate with ADT or require manual entry based on dictated information. Mandatory and Additional ADT fields will change based upon client facility/work type of the current job.

Note: A blank mandatory ADT field does not necessarily route a report to another stage/person before being sent to the client.

ADDITIONAL ADT SECTION (bottom right section) Optional ADT fields Fields will populate with ADT or require manual entry based on dictated information. Typically this is where you would find such fields as Date of Service to complete as well as several provider lookup fields (i.e., Referring Doctor) that are pertinent to the patient’s visit.

Note: A blank additional ADT field will not route a report to another stage/person before being sent to the client. Tip: To enter current date in any date field, such as Admit Date, Discharge Date, etc., use Ctrl+T. Use Ctrl+Y to enter yesterday’s date. Use + and - to increment and decrement the date in the date field. This shortcut is based on the current date and time on the DocQscribe user's computer NOT the dictated date and time.

ADT Matching Scenario 1 - Patient demographic data populates automatically:

All ADT demographic information must be verified. Information dictated takes precedence over what is populated.

Scenario 2 - Patient demographic data is not completely populated

Search for the ADT based on what is dictated utilizing the different search fields that are available. Dictated information takes precedence over what is ADT database.

Scenario 3 - Patient demographic located - cannot confirm correct visit

If the patient's name and medical record number have been located however the correct visit number cannot be confirmed, click on the "Accept Just Patient" button to insert the patient's information only.

Note: It is the responsibility of all DocQscribe users who access a job to ensure that the ADT used on the job matches the patient and visit information from the dictator. Incorrect ADT could cause multiple negative impacts to the report and ultimately could affect patient care.

Dictated for ADT Additional field (located underneath mandatory ADT demographic fields) This is not a common practice in most facilities. The Dictated For ADT Additional field is to be used when a signing physician is dictating for another signing physician. The Dictated For dialogue box will not appear in the ADT demographics screen. Example: One attending physician dictating for another - in this case, the attending dictating would appear in the dictator field and the signing physician would be the dictated for. Dictator may state "This is Dr. Williams dictating for Dr. Jones" or "This is Dr. Williams covering for Dr. Jones." Date of Service The Date of Service field is used to populate some of the following fields: Date of Procedure, Date of Operation, Date Seen, Date of Consultation, Exam Date, Procedure Date, etc. Field may be in mandatory or additional ADT window; must manually populate when dictated. If not dictated or provided in the ADT, do not add.

Note: If you need to refer to the dictation date, the date/time dictated displays in Eastern Time Zone in the ADT demographics window.

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Physician Fields Referring Doctor, Attending Doctor, Assistant, PCP, etc. Populate from database as dictated. Refer to the Available Names Database section. ADT Attending, ADT Referring, etc. Data that populates a field beginning with "ADT" is information provided by client however may not sufficiently meet all of the requirements to complete the report. The client profile will specify if this data needs to be re-picked or populated in an additional ADT demographic field. Available Names Database The available names database is inclusive of all dictators, referring physicians, local staff, locations, etc. for a client or group of clients. Searching When using search fields (last name, first name, specialty or access code), remember that you can and should use the wild card of % if you only have partial information. Try single field searches, or narrow down with partial multiple search fields. Need to think outside the box on possible spellings. View Option Allows the transcriptionist to view all available information that is not seen in the names window.

New Contact Option When required to fill in a physician field and name is not available in the database, or there is more than one choice in the database and not enough info given to choose, use New Contact. Manually enter fields as dictated. (Ex: There are 5 Dr. Smiths in database and first name not stated. Enter as Last Name: Dr. Smith.)

Note: If a fax number is dictated for a contact that is not located in the database, transcribe the fax number in the Last name field after the last name that is dictated to ensure that the fax number will appear on the final report for the client.

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Incomplete Dictation Instructions INCOMPLETE OR CANCELED DICTATIONS 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. Enter two lines and transcribe in all capital letters - DICTATION ENDS HERE. 2. Create a QA/QC Note stating DICTATION ENDS HERE. This process does not require the report to be sent to QA manually.

NO DICTATION MedQuist MTs are instructed to edit the work type entered by the dictator to a "no dictation" work type when the audio associated with the voice file submitted by the dictator does not contain dictation which could be transcribed. Examples include, but are not limited to, jobs with preamble information (dictator identifying himself and/or other information) and then ending the dictation file without continuing with the dictation; dictator enters the dictation job, may say a few words, but then records hold music, silence or static; dictator begins the dictation, perhaps identifies the patient, but then states that she/he will dictate later or this dictation has already been completed, etc. 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 the No Dictation work type. 3. Upload the job. This process does not require the report to be sent to QA manually.

ADDENDUM/CONTINUATION If dictator states he/she is dictating an addendum/continuation to a previously dictated report, you should:

1. Change work type Addendum work type if available. If the Addendum work type is not available to choose in the work type list, leave the work type as entered by the dictator. 2. Type ADDENDUM or CONTINUATION at the top of your report in a red tagged heading. 3. Transcribe as dictated. 4. Create a QA/QC Note stating ADDENDUM or CONTINUATION. 5. Upload the job. This process does not require to be sent to QA manually. </ADDENDUM/> The patient will follow up with the Primary Care Physician…….. </PLAN/> The patient will begin with physical therapy……..

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QA/MME Instructions QA Marker Protocol If a QA Marker cannot be resolved, leave the QA Marker in the text of the document. QA/QC Note Protocol The client can view and/or print QA/QC Notes. Therefore, make sure there are no derogatory remarks in the QA/QC Note. Keep comments specific to the issue such as "advise on spelling", "Injury dictated to right hand under History, but left hand under Hospital Course." Do not put "sounds like …..", "s/l …" etc. The transcriptionists must describe the discrepancy within the report to guide the QA staff appropriately in his/her research. Ex. Dosage does not match medication. MT can ask questions in the QA/QC note about the client profile. Key Reasons to use the QA/QC Note for QA Staff - Addendum/Continuation. - Incomplete Dictation. - Discrepancy in the report (stated right shoulder at beginning then left shoulder at end of dictation). - Courtesy copies that are unintelligible (refer to Courtesy Copy section for specifics). - Blank in a report

Note: The QA Markers will match the voice files as long as they are inserted during transcription before the voice file completes (beeps) at the end.

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Work Type Specific Instructions Any unique information pertinent to a work type will be noted under the Work Type Instructions Category. Mandatory WT Standard Protocol If there is a mandatory work type standard that is required to be used to transcribe a specific work type, this will be noted in the work type specific instructions. All headings tags included in a standard are to remain in the body of document even if not dictated. If there is nothing dictated for a specific heading, remove the @@ code only. Letter Format Protocol A letter is formatted in one of the following two options, depending on client preference: OPTION 1 - Mandatory Letter Standard that includes only </ADDRESS/> and </BODY/> tags.

Note: Do not remove any headings. Do not transcribe anything other than </ADDRESS/> above the </BODY/> tag.

- Do not add date to top of report. Populates from ADT. - Do not add RE: (patient name), MRN or DOB, etc. Info will populate from ADT. - Salutation: If not dictated, transcribe “Dear (Dr., Mrs., Ms., etc) Last Name:” - Closing: To be transcribed as dictated. If not dictated, transcribe “Sincerely,” - Do not add signature line. Populates from ADT.

</ADDRESS/> Test Doctor, MD 1234 5th Street Test City, US 98765 </BODY/> Dear Dr. Doctor: I had the privilege of consulting your patient… Sincerely, OPTION 2 - Mandatory Letter Standard that includes </ADDRESS/>, </BODY/> and </CLOSING/> tags

Note: Do not remove any headings. Do not transcribe anything other than </ADDRESS/> above the </BODY/> tag.

- Do not add date to top of report. Populates from ADT. - Do not add RE: (patient name), MRN or DOB, etc. Info will populate from ADT. - Salutation: If not dictated, transcribe “Dear (Dr., Mrs., Ms., etc) Last Name:” - Closing: To be transcribed as dictated. If not dictated, transcribe “Sincerely,” - Do not add signature line. Populates from ADT.

</ADDRESS/> Test Doctor, MD 1234 5th Street Test City, US 98765 </BODY/> Dear Dr. Doctor: I had the privilege of consulting your patient… </CLOSING/> Sincerely,

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Dictator Specific Instructions Any unique information pertinent to a dictator will be noted under the Dictator Specific Instructions Category.

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Physician Nomenclature

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Appendix Demographics and ADT Screen Information

ADT Demographic Information - Clarification of each field DEMOGRAPHIC SECTION (top left section) Client Facility This field will show the client facility name as it appears in DEP. Internal Job Number The Internal Job Number is the unique identifying number assigned to the job by DEP. This number will never be duplicated. Dictation Job No The Dictation Job Number is the identification assigned to the audio/dictation file. This is not a unique identifier. It can be used by the dictator and the client for dictation documentation. Split Jobs will use the same dictation job number as the master/originating job. The Dictation Job No should not be edited. Date/Time Dictated The Date/Time Dictated field populated with the date and time the report was dictated

Note: The Date/Time dictated will always appear in Eastern Time Zone.

Transcribed By This field will populate with the DocQscribe user names of anyone who transcribes or edits the job. This information will populate appropriately as changes are made and saved to the particular job in DocQscribe.

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Function Reason Explains why a report routed to QA. QA should look at this section on every job. Could include one or more of the following: - QA Marker(s) found in text - QA Rule for Client Facility, DocQscribe User, Dictator or Work Type = 100% review - Always added for this type of job = 100% review for ILP - Added by DocQscribe User = User checked box to send to another stage

Available Names Database (Control N) Searching When using search fields (last name, first name, specialty or access code), remember that you can and should use the wild card of % if you only have partial information. Try single field searches, or narrow down with partial multiple search fields. Need to think outside the box on possible spellings. Search by name ending. Possibly “sky” or “ski” (try search using both spellings)

Search by “portion” of name. not sure of beginning or end.

Search by partial last name. Narrow down by including all first names beginning with B.

Search by specialty. CAR will bring up all physicians with Cardiovascular, Cardiology, Cardiothoracic, etc (whatever specialty name facility uses).

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