WHEN EDITING A DOCUMENT, YOUR OBJECTIVES SHOULD BE TO:
- Edit for content, not cosmetics.
- Increase productivity and efficiency.
- Always make necessary edits.
- Submit an accurate medical document.
When transcribing, it is very simple for us to improve what we hear structurally and grammatically. As we listen to the dictation, we can easily change what is spoken as we type it. We can make dictators look better. Unfortunately, when editing drafts, this is neither easy nor recommended. When editing drafts, we may be tempted to overedit. Overediting often involves changes to grammar, punctuation, dictation style, and readability. Making such edits can be unnecessary. The task of the MTE is to ensure the medical accuracy of the submitted document – not to make the document ‘picture perfect.’
Here is an example of a submitted draft document where the MTE did not overedit. Notice that one could easily ‘clean up’ the grammar and readability of the draft, but the medical accuracy is perfect!
Toothache, needs dental work. Concerned blood pressure will be too high to get this done. Taking her chronic blood pressure medications without any side effects. Had blood work drawn. No neurologic, cardiorespiratory, peripheral vascular, or other end-organ symptoms.
Understandably, some accounts may require more editing than others. Talk to your account manager or supervisor about what may or may not constitute as overediting.
We each must create our own definition for overediting. It is a fine line between editing and improving readability or grammar. When editing, keep overediting in the back of your head and ask yourself if all the edits you are making are really necessary.
WHEN IN DOUBT, ALWAYS EDIT:
- Left/Right Discrepancies
- Gender Discrepancies
- Measurements in Lab Results
- Inconsistencies in Medication Dosages
Let’s look at another example:
Draft reads: NECK: Supple there is no nuchal rigidity.
A. NECK: Supple, there is no nuchal rigidity.
B. NECK: Supple. There is no nuchal rigidity.
C. NECK: Supple and there is no nuchal rigidity.
D. Leave as is.
Which would you choose?
In both A and B, the number of keystrokes to make the edit is 1. In A, inserting a comma is just one keystroke. In B, if you insert the period correctly, AnyModal Edit will auto-capitalize the word ‘There.’ Both A and B are correct.
The answer C would be considered overediting. The meaning of A, B, and C are all the same, but C requires 4 keystrokes – the word ‘and’ and the space between ‘and’ and ‘there.’
Both C and D are incorrect. It would not be correct to leave the sentence as-is. Without the punctuation, the sentence makes no sense.
- Correct readability, but do not improve it.
- There is a fine line between editing and tampering.
- Correct inconsistencies and discrepancies in your documents.
- Transcribe and edit for medical accuracy, not cosmetics!
Until next time,
Bethany at M*Modal