Whenever a new "customer" (per our company's policy, we no longer have patients...or clients...they are "customers") is admitted to our program, I perform an hour to hour and a half comprehensive medical history and physical examination. I then dictate this assessment, identifying all pertinent diagnoses...from ingrown toenails to head lice to whatever...and develop a treatment plan with referrals and recommendations for additional care needed beyond my scope of practice..i.e. ...dental, vision..etc. This dictated document is generally 5-6 typed pages. In an interesting cost savings maneuver, our transcription service has been farmed out to someplace in Nepal. Yes..Nepal. We are in Alaska. Global community? Whatever. Anyway....there are some interesting and unique interpretations of medical descriptive terms that have come across my laptop for editing. Such as:
Under medications, herbs, nutritional supplements:
My dictation: " reports chamomile tea several times daily for relaxation"
The finished transcript: " reports camel milk tea several times daily..." cute. But it costs me time/keystrokes to make the edits, and if my records ever ended up in court for any reason...i can just imagine some attorney grilling my but about where folks get camel milk in Alaska....
My dictation: "complains of discharge with foul odor"
The finished transcript: "complains of discharge, smells like chicken".....it took me a second...foul..fowl..chicken....
I am not making this up!