The editing done by MTs is so important that it is included in AAMT�s MT Bill of Rights, in the organization�s strategic plan and in the AAMT Book of Style. �AAMT gives clear instructions,� Parker pointed out. �We need to edit, but we must edit gently.�And there is an art to editing gently. Improving readability without changing the dictator�s style or medical meaning requires great precision. Under-editing by ignoring proper spelling or committing a physician�s malapropism to paper can muddy the messages in the patient record. Over-editing, by cutting out seemingly unimportant (yet often vital) data such as �normal� test results, can deprive the physician of critical information.
Sometimes necessary revisions are obvious and can be made without hesitation. Other instances may draw harder on MT�s expertise, requiring research and patience.
Grammar
Examples of obviously necessary revisions are corrections to poor grammar, word choice (as in the samples above) and punctuation. For instance, the proper usage of lay and lie is a mystery to many people, physicians included. (Lay is an action word that takes a direct object, as in, �please lay the book on the table.� Lie means to recline and does not take an object.) If the dictator says, �the patient wanted to lay down,� the MT can easily record the proper form, �the patient wanted to lie down,� without any alteration to the dictator�s meaning or style. Medical reports are subject to all the basic rules of English, and according to Parker, it is the MT�s responsibility to do his or her best to ensure that those rules are being followed. In general, if the physician breaks a grammatical rule (i.e., saying �data is� instead of �data are,� using �or� instead of �nor,� or neglecting to use �whom� where appropriate) or chooses the wrong word (i.e. diverticuli rather than diverticula), it is perfectly acceptable to fix it. �The doctor�s job is to treat patients,� asserted Parker. �Knowing all the grammar rules isn�t part of that. But it is an important part of being a medical language specialist, and it is our job to give them the benefit of our knowledge.�
Sentence Structure
Likewise, changes to sentence structure are allowable when the change will clarify the speaker�s meaning without altering it. For example; �she recently had blood work and everything was normal with her physician,� may be uttered in a way that it makes sense to the ear, but it should be rephrased as, �she recently had blood work with her physician and everything was normal,� to make sense on paper.
Physicians for whom English is a second language pose a particular challenge for MTs. �Often a foreign language dictator will use the correct English words, but arrange them according to the grammatical rules of his or her primary language,� Parker pointed out. �MTs provide a valuable service to both the dictator and the reader when they can restructure these sentences to conform to the rules of English grammar.�
Rearranging a dictator�s phrases in the proper order is acceptable. Completely restating his or her thought, however, is not. If the sentence is grammatical and accurate, Parker advises that you leave it alone, even if you can think of a �better� way to say it.
Spelling
Spelling, on the other hand, is an area in which transcriptionists are free to do a little second guessing. �Never accept a doctor�s spelling,� cautioned Parker, �If you�re not sure, look it up. If the word you need is not in your reference books, ask around. Call health food stores to get the correct spelling of herbal remedies. Call a pharmacist to learn how to spell a new drug. Find out for sure.� Above all; Parker cautioned, never just take a guess � about spelling or anything else you transcribe. �Guessing will make you look foolish,� she warned. �It will reflect poorly on your skills.�
Slang
Whether spelled correctly or not, some words are not appropriate in a medical record. Derogatory or inflammatory remarks do not belong in the report � with the exception of direct quotes, which must be written verbatim. Parker suggests that if a dictator uses inappropriate language, excise it if possible; otherwise flag the report.
Slang terms are similarly inappropriate in the legal record that is a patient chart. �I never transcribe slang,� offered Parker. �For example, If the doctor dictates the patient has a past surgical history of appy,� this should be changed to �appendectomy.� Or, if he or she dictated �trach,� it should be transcribed tracheostomy. tracheal, or tracheotomy. The correct word will be evident from the rest of the report.
It is sometimes difficult, however, to distinguish slang from a valid back-formation or an accepted coined term. For example, the term coumadinize is a back formation from the drug name Coumadin. Previously considered slang by most MTs. it is now an accepted medical term, validated by its presence in medical references and word books. When in doubt about the legitimacy of a term, Parker recommends first enlisting the help of other transcriptionists. �If you still aren�t sure and you�re a member of AAMT, call the main office and ask someone there,� she offered.
Inconsistencies
One of the toughest challenges MTs face is clarifying inconsistencies in the report. �If, for example, the physician has been referring throughout the dictation to the right leg and suddenly begins referring to the left leg, that is a serious inconsistency,� noted Parker. MTs may correct inconsistencies, but only if the documentation clearly supports it. �In this instance, it is acceptable to look at the X-ray or operative report to determine if the physician was indeed referring to the left leg. If there is no verification do not make the change. Instead, flag the report and ask the physician.�
There is no shame in flagging a report for any of the aforementioned reasons. �Don�t make any change that you are not sure of,� Parker stressed.
Remember, the art of editing requires a gentle hand. The changes you make should be almost imperceptible. �Your ultimate goal,� explained Parker, �is to make all the doctors think that they are really good dictators.�
Gretchen Berry is an assistant editor at ADVANCE.
ADVANCE for Health Information Professionals � May 10, 1999