Washington Outpatient Surgery
Center (WOSC) Account Details
Jobs: The customer number is 009, outlined in purple. The Santa Clara/Acusis Job#
follows the customer number. The Customer Job# is outlined in green. The physician
name is also shown and "wash" for Washington (Outpatient Surgery Center) (WOSC).
Notes: The font for WOSC is Courier New 12. NOTE: Presently in Word Script the
font is not set to be CN12 100% of the time. Mixed fonts do not matter at this time. If
you insert a normal and the font is different from the text of your document, it is okay to
send it as is.
Work Types:
10
13
18
99
Pre-Op H&P/Consult
Op/Procedure
Endoscopy
Administration
ADT Information: EXACT MATCH - You must only select an ADT that is the
same date of service as given by the dictating physician. The MRNO and patient
information must match. Frequently, however, WOSC does not have ADT available. In
this case you can send the report directly to the customer after ensuring the billing field in
Data Input Window is cleared. You do not have to send No ADT jobs to editing.
Please do a manual search if no ADT automatically populates upon opening the job. You
can search by any/all of the criteria available on this page. You can also search partial
names or values by clicking the checkbox next to that field. Click on Search to execute
search function.
Dates: The ADT is most accurate, so use the date of service listed in the ADT. If there
is no ADT, use the date dictated. If the ADT shows one date and the dictator gives
another, use the date in the ADT.
Data Input Window:
DATA INPUT WINDOW
Acusis Job Number
Auto-populated
Customer Job Number
Customer
Work Type
Billing Number
Auto-populated
Auto-populated--do not change; alert techs if error
Correct the Work Type appropriately
Leave Blank
Medical Record Number
Last Name
First Name
Leave field blank if no medical record number
dictated or when medical record number cannot be
located based on ADT
Type No Name
Type No Name
Dictate PhyID Copy
Auto-populated. If unknown leave blank and
send to editing with a note.
Auto-populated
Auto-populated
Admit Date
May or may not auto-populate; MUST use
SERVICE DATE field
Discharge Date
May or may not auto-populate; MUST use
SERVICE DATE field
Surgery Date
Service Date
Do not use this field. Enter this information in
SERVICE DATE field.
Date as dictated, or leave blank
Date of Consult
Do not use this field. Enter this information in
SERVICE DATE field.
Dictating Physician
Dictating Physician ID#
Carbon Copies: To add CCs for WOSC you will use the CC tab in the Data Input
Window ( ). You can add a CC three ways: database drop-down selection, free-form
entry, or CC search selection. See Carbon Copies in Word Script or Transcribing in
WordScript posted under Word Script Users on our website Headlines page for detailed
instructions.
If you are unable to understand the CC recipient, use the free-form CC menu and insert a
blank of 10 underscores into the field(s) in question.
If the CC recipient is not in the database and is not spelled by the author, spell
phonetically.
TRANSCRIPTION INSTRUCTIONS
Edit grammar, punctuation, spelling and similar dictation errors as necessary to achieve
clear communication. Likewise, edit slang words and phrases, English or medical
inconsistencies, and inaccurate phrasing of laboratory data. Do not transcribe
contractions; always spell out contractions when dictated. Do not abbreviate medications
or use slang medication names; always transcribe the complete brand-name or generic
name of the medication. Do not tamper with the meaning of the report of with the
dictator's style. Editing which leads to rephrasing of the dictation or tampering with the
dictator's style is not allowed.
Please refer to more specific details noted below.
Abbreviations & Acronyms: Common abbreviations and acronyms are acceptable
on this account and are to be transcribed as dictated unless in the DIAGNOSIS and
PLAN sections. In this case they are to be spelled out, with the exception of very
common abbreviations such as lab values, CT, MRI, CMV PCR, etc. If you are doing a
procedure note work type if following the PROCEDURE header the actual procedure
name is what is abbreviated then it would be spelled out. For example, ORIF would be
open reduction, internal fixation while MRI-guided biopsy would not be spelled out. Do
not guess at an abbreviation that has more than one meaning. For example, if ALL is
dictated only in the diagnosis and nowhere else in the report clarifies whether it is acute
lymphoblastic leukemia or acute lymphocytic leukemia then it is okay to leave it ALL in
the diagnosis.
If you spell out the uncommon or not easily recognizable abbreviation please add the
abbreviation or acronym following it in parentheses.
ASG Exception: Dr. Ellner does not want any of his numbers as ordinals. For example,
if he dictates first he wants first typed and not 1st.
IMPORTANT ACCOUNT INSTRUCTIONS
Format: Headers are in caps. Text starts under the headers except for certain headers
such as those noted below, where the text indents to 2.5 and is set with a hanging indent
using the Ctrl+T command, not the tab bar.
SURGEON:
ASSISTANT:
ANESTHESIA:
ANESTHESIOLOGIST:
Steven C. Andersen, M.D.
None.
Monitored anesthesia care.
and
EYES:
ENT:
LYMPH NODES:
NECK AND THYROID:
THORAX AND LUNGS:
Pupils equal, react to light and
accommodation. Extraocular
motions normal.
No evidence of inflammation
detected.
No lymphadenopathy palpable.
Thyroid gland not palpable.
Air entry good, breath sounds
vesicular. No crepitations heard.
CARDIOVASCULAR:
ABDOMEN:
EXTERNAL GENITALIA:
Heart sounds 1 and 2 normal, no
murmurs detected.
Soft. Liver, spleen, and kidneys
not palpable. No masses detected.
Within normal limits for age.
Patient Names: In body of report it is okay to use the patient name if dictated.
Normals: Some of the doctors use Normals for routine dictation. These Normals are
accessed using the Normals button (
information as dictated by the doctor.
)(Alt+Shift+Q).
Fill in the variable
Be sure you use the correct normal for the dictation. For detailed instructions on how to
download, access, and insert Normals see Demographics, Templates, and Normals
posted under Word Script Users on our website Headlines page for detailed instructions.
No-Voice Reports: If a job has no audible dictation other than pertinent patient
information dictated--meaning there is no actual report text to be transcribed--use the No
Voice/Corrupt button on the bottom left of the Doubt reason screen. Leave the document
blank and send the report as normal. You do receive keystrokes for these reports.
Incomplete Dictations: If a dictation ends abruptly, is cut-off or for whatever reason
appears to be incomplete, send it to Editing with the appropriate message selected. At the
bottom of the report on the left margin type: DICTATION ENDS HERE.
Multi Reports: While not common with this account, it may be that you get one job
that has more than one report dictated. Use the Insert Template function to create
multiple reports per posted instructions.
Addendum: Type an addendum as you would any other report. Type ADDENDUM:
at the top of the report, adding the prior job number if given.
CC Addendum: When an addendum is only a carbon copy or includes a carbon copy
DO NOT use the drop-down or free-from CC menu. Type the CC directly into the
document under the ADDENDUM: header and send to the customer.
Correction Addendum: The only exception to sending an addendum to the
customer would be if the addendum is clearly a detailed correction/edit of a completed
job in their possession the dictator is making corrections to where he would like edits
made and the job resent. This is not to be confused with an addendum of job where they
might be dictating a correction of and they are not editing a report they have received.
This sounds rather confusing, so, for example:
D: On that last job please add 6-week history of pain and that an MRI was done which
was negative.
Type as dictated and send this to customer.
D: On job 123456 in the HPI change 6-month history of pain to 6-week history of pain.
In the PE change no rebound or guarding to say there is rebound and guarding.
Type as dictated and send to editing. This is clearly a correction of a job in the doctor's
possession they wanted edited and resent.
New/Unknown Dictators: When you encounter an unknown dictator in WS, simply
remove the dictator's name from the Dictating Physician field in Data Input Window
(assuming that the dictator is using someone else's ID to dictate.) Leave the field blank
and send it to editing with a Doubt reason of: Review, with a description of: Dictating
physician not in database.
Rev. 03/23/09 ach