Follow the Map and You Won't Get Lost

Transcriptionists often use templates to format and standardize dictation from doctors. If a doctor does not dictate any information for a particular field in the template, the transcriptionist simply deletes that line from the template when editing the report.

Look at the template frequently used for documenting a patient's physical findings:

PHYSICAL EXAMINATION:

General:
Skin:
Vital Signs:
HEENT:
Neck:
Back:
Chest:
Heart:
Abdomen:
Genitalia:
Pelvic:
Rectal:
Extremities:
Neurologic:

This template is a roadmap for inserting information into a document. How does it work?

For every patient whose examination you describe, you start at the top and work your way to the bottom.

Follow the road map carefully and you won't crash. It's that simple.

[Cartoon #6 ]

Next: Garbled Messages

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