Wednesday Transcription Tip- Demographics
Today's Transcription Tip comes from one of our instructors, Brenda Dorsett, CMT.
Before we type the first word of any report, we must first pay special attention to the demographics for the report. Accurate patient demographics are critical to patient health information. Demographics give the patient information identification. Demographics are provided by manual entry of identifying information by the dictator into some device that will be used by the dictation system interface. Demographics are also provided by spoken dictation.
Pay meticulous attention to:Patient name:
- First, Last, Middle correct spellings
- Helen versus Ellen - Names that sound similar
- Gender confusing names such as Francis versus Frances, Bobby versus Bobbie
- Interchangeable names – Names that could be first or last, such as James Allen or Allen James.
- Occurrences of Jr and Sr (Junior and Senior)
- Patients of same names such as mother and daughter or common names like Mary Smith, Richard Jones, etc.
- Hyphenated names (Smith-Jones or Jones-Smith)
- Nickname usage such as Rich, Rick, or Dick for Richard
- Physician identifier – names and numbers correct
- Correct Dates: Admission, Operative, Discharge, Transfer, Death, etc, Date of Service, Birth dates
- Medical Record Number
- Account Number/Visit Number/Order ID
- Female versus male (he versus she, him and her)
- Be sure that the correct report type is going to be typed such as Operative versus History and Physical, etc.
The transcriptionist must remain cognizant through the entire report for these things and fix or report any inconsistencies. Sometimes the transcriptionist has the ways and means to view the records system for verification purposes. If not, then no guessing; the report needs to be flagged and verified.