How Verbatim is Verbatim?
Posted on 10.01.2015
By definition, verbatim means “in exactly the same words as were used originally,” but is that really how medical transcription and editing is performed? More specifically, is that what is expected when sitting for pre-employment tests? In a word: No. Let’s look at why as it relates to the goal of the medical record.
The goal of the medical record is to provide a clear picture of past and current history and treatment, contraindications, and future treatment plans. With that in mind, think about how transcribing every single word the author of the report dictates might affect that goal.
For example, you have likely heard dictated something similar to this: Transcriptionist, please add hypertension to the diagnosis. According to the definition stated in the outset, the transcriptionist would be required to type that exact sentence, word for word, right where it was dictated. Hypertension would never actually be added to the diagnosis list; it would simply linger within this strange little sentence somewhere midway through the report. Certainly this would not contribute to the goal of the medical record.
The same reasoning can be applied to other scenarios, such as when an author starts to dictate a report but then realizes he’s dictating for the wrong patient and starts the report over or when he stumbles over words or restates the same sentence.
If strict verbatim—verbatim according to the definition—is not how a medical report should be transcribed, then how verbatim is verbatim?
Again, keeping the goal in mind, consider these general rules of thumb:
- Make minor edits to correct grammar and punctuation.
- Follow the author’s dictation style as long as the meaning is clear.
- Flag anything that may require major editing (for example: ambiguous or incoherent sentence structure).
- Flag contradictory or questionable information (left/right, unverifiable medication dose, critical lab value not mentioned elsewhere in the report, etc.).
- Expand abbreviations that are part of the patient’s diagnosis under diagnosis-type headings (assessment, impression, etc.).
- Expand abbreviations that are part of the procedure list in operative reports.
- Transcribe headings as dictated.
- Flag incorrect terminology and headings if the correct term or heading cannot be determined.
- Omit exact redundancies (This morning the patient presented to this office this morning.) but transcribe similar information as dictated (Informed consent was obtained. A timeout was performed after informed consent was obtained.).
Remember, the goal is for an easily understood medical record, so avoid the extremes of turning it into a novel by over-editing and of leaving it an incoherent mess by under-editing. By doing so, you will maintain the integrity of the medical record and its author’s style while adhering to the instruction to transcribe verbatim.