The Medical Transcriptionist Procedure for Flagging

Flagging a medical report is necessary when a Medical Transcriptionist leaves a blank or has some other question about a report.

It is important to learn and follow the department or employer’s policy for handling questionable dictation. Most employers insist that their Medical Transcriptionist leave blanks rather than to “guess” or make up dictation to avoid leaving a blank.

Consider the following steps as a customary hospital and clinic policy for leaving blanks and flagging:

• Seek the supervisor’s opinion or that of another Medical Transcriptionistn • Refer to the patient’s chart if availablen • Contact the dictating physician to ask about the word in question. This is often handled by the supervisor or lead transcriptionistn • Leave a blank in the report and attach a flag to the dictator’s attentio

You will probably get different responses from different physicians. Some physicians may give you information above and beyond what you ask for, which may include entire articles out of texts or journals to answer your questions. Other physicians will simply write the words on your flagging note.

A problem you will encounter with posting notes is those that are paper clipped to the report or a post-it note can fall off. Notes need to be worded in an extremely tactful manner. The person to whom the note is directed can take offense when none is intended.

Another problem is most likely the Medical Transcriptionist will never see the printed copy of their reports. Printers are often in another location and another person is assigned to sorting and charting. One solution is to create a standard memo to accompany the report just like another page of the report. The memo may include:

• Patient’s namen • Other pertinent informationn • Boxes or blanks to check for the problem encountered and a place to fill in the “sounds like.”

In either case as with using sticky notes or a standard memo, it is always important to remember the professional Medical Transcriptionist who desires to produce the most accurate, highest quality report possible will leave a blank and will learn from each blank he or she has to leave in medical dictation.

I have worked in both types of environments, one in which we all used a note paper clipped or a sticky note and the other where there is a standard memo attached to each transcribed report that floats along as part of the entire document wherever the report goes.

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