That is the question! When transcribing, it is very simple for us to improve what we hear structurally and grammatically. As we listen to the dictation, we can restructure, reorder, or manipulate what is spoken as we type it. We can easily make dictators look better on paper. Unfortunately, when editing drafts, this is neither easy nor recommended. Edits that could be considered over editing often involve changes to grammar, punctuation, dictation style, and readability. Making these edits can be unnecessary, as well as cumbersome. The task of the MTE is to ensure the medical accuracy of the submitted document. The MTE needs to consider editing the sentence efficiently, not cosmetically. Efficient edits are those that are acceptable and accurate, while minimizing keystrokes.
Over editing is open to debate between individuals and organizations alike. Understandably, some accounts may require more editing than others. When learning to edit, the MTE is to consider which edits are necessary, and which are made to improve the readability of the document.
When in doubt, always make certain to edit the following. These should never be considered over editing!
- Left/Right Discrepancies
- Gender Discrepancies
- Measurements in Lab Results
- Inconsistencies in Medication Dosages
Some of the most common edits that we see being made to the drafts can be considered over editing. Sometimes the edits actually go against the newest AHDI Book of Style recommendations and industry trends. Other times, the draft has output one acceptable form of a word or phrase and the MTE edits it to another acceptable form. Unless specifically required by your account, these edits would be considered over editing:
- L1-L2 and L1-2 are both acceptable when denoting intervertebral spaces
- He was tried on 3 different medications (spelling out the “3” is not necessary)
- Right 5th finger and right fifth finger are both acceptable
- 2 cm incision (do not add a hyphen with numeric values and metric units per AHDI)
- MiraLAX is correct! Do not change to MiraLax.
- African American and African-American are both acceptable
Again, please check with your account manager to see if your account has specific requirements involving any of these types of edits as client preference is always the final say. But if they don’t, then do not use your time to make edits that are unnecessary. It will make you less efficient and decrease your productivity.
Have a question about over editing? —Let’s Talk!