QASAR FEEDBACK GUIDELINES AND TOOLS

Transcription

1 FEEDBACK GUIDELINES QASAR is the primary source of QA feedback for the Medical Transcriptionist population. How reports are edited, especially when they are fully listened to, is crucial in providing a consistent standardized assessment of the MT s work. This consistent feedback allows the MT to focus on and address areas of deficiency. Uniform application of the QASAR tool can result in decreased submission of QA Markers. Error Types and QA Markers You are required to insert a QA Feedback tag for any corrections made in a report. At present, use the default Feedback Type, A - Quality Assurance Feedback, with the Feedback Subtype (*). This ensures that no point value is assigned to the edits. If at any time you are unable to resolve an issue, whether the edit is for a QA Marker or other text, leave a QA Marker within a QA Feedback tag. Enter a reason in the Comments box so the MT is aware of why you left the QA Marker. QA Markers sent back to the customer within a QA Feedback tag will format on the back-end according to the customer s specifications. Concentrate on the Major Issues Focus first on critical errors that could have a negative outcome in patient care. The following are examples of critical errors: The dictator states "A WBC of 11.3" and the transcriptionist types "An RBC of 11.3" The dictator states "The patient did not have chest pain" and the transcriptionist types "The patient did have chest pain" The following examples are not critical errors and would not negatively affect patient care: The dictator states "A WBC of 11.3" and the transcriptionist types "A WBC 11.3" The dictator states "The patient did not have chest pain" and the transcriptionist types "Patient did not have chest pain" Ask yourself these questions: Does this error affect patient safety? Does this error affect the integrity of the document in a major way? Is the issue in direct conflict with the Client Profile or the MedQuist DocQscribe Standards and Guidelines? Is the issue in direct conflict with the AAMT Book of Style? If the answer is yes, the error should be marked and corrected. If the answer is no, think about whether or not the error should be marked and/or corrected. Leave the Little Stuff Alone Be careful of over editing and personal preferences when performing the QA function. Keep in mind that sometimes terms can be referenced in more than one place and in more than one form. Be certain that your way is the only way if you are going to correct something. When deciding on whether or not to correct an issue, ask yourself the aforementioned questions. If the answer is no, refrain from providing feedback. We promote the preferred/recommended guidelines in the AAMT Book of Style although, at times, there are acceptable alternatives. If the customer does not have a specific preference, and the MT typed an acceptable alternative, then do not edit the text. If the edit does not affect patient safety or the integrity of the document, you might want to provide FYI feedback in the Add General Comment section of QASAR. Hyphens, Punctuation, Commas Unless it changes the meaning or integrity of the sentence, refrain from correcting or providing feedback. There are multiple schools of thought on hyphenating words. Even AAMT is changing its recommendations. Look for uniformity. Obvious grammar, punctuation, and structural errors should be edited with QA feedback provided to the MT. Otherwise, make your feedback an FYI using QASAR as an educational tool by entering your suggestions in the Add General Comment section. Example: COSURGEON corrected to CO-SURGEON. This would not require correcting. 1

2 Leave Comments QASAR feedback is the primary forum for mentoring the MTs and sending them helpful information. Unless your correction is clearly self-explanatory, enter a reason for the edit in the Comments box to let the MT know why you made the change. Remind the MT of overlooked Client Profile instructions by copying the applicable statement using the function available in the Add Text Feedback window. Additionally, entering a general comment for items that do not require correction is the best tool for educating MTs about noncritical errors, for example, no hyphen necessary with the prefix non. To leave a general comment without marking text in the report, press Alt + Q and then C or click QA Feedback > Add General Comment. If you referenced a term somewhere, provide that feedback. Perhaps it was a useful Web site. Put this in the Comments box. The goal is to educate the MTs to make them self-sufficient and decrease their submission rate to QA. To address an MT who frequently uses commas or does not use them at all, use the Add General Comment section to give them an FYI to watch their punctuation. For example, "less is better as far as commas are concerned" or "please place commas at the natural pauses" are appropriate comments. Keep all feedback friendly and positive. Constructive criticism should be provided in a professional manner. Refrain from typing in all caps; it gives the impression of SHOUTING! Practice good etiquette when entering your QA comments. Give a Pat on the Back Once in a While You should be just as quick to praise as you are to correct. If you see a report that is well done, or the transcriptionist did an exceptional job on a difficult dictation, take a few seconds to write a quick note of praise. Even "Nice job!" is an appreciative note. It takes two seconds to add, but will be remembered far longer. Just include it under the Add General Comment section. WORKING WITH STANDARDS Browse Standards You can browse Standards to assist in verifying that the correct Standard was inserted during transcription. 1. To view Standards without inserting them into the job, press Alt + Q and then S, or click QA Feedback > Browse Standards. The Browse Standards tool provides two viewing options: The default option displays the Standards in a popup box, which displays on top of your report. The second option allows you to view Standards in a window next to the transcribed text in a "Compare Side by Side" mode. 2. Press the Up Arrow and/or Down Arrow key or click the name of the Standard in the list to navigate to and view the contents of the appropriate Standard. This is a view only function. To correct the Standard or insert a new one, refer to Inserting a Standard. Inserting a Standard You might need to reformat some or all of the text because an incorrect Standard was inserted or a Standard was omitted. Once you insert the Standard, leave QA Feedback as necessary for additional edits within that text. Refer to Working with Nested Feedback for instructions on how to leave additional QA Feedback tags when working with Standards. To insert a Standard that affects a portion of the report: 1. Highlight the block of text to be corrected with a Standard. The cursor defaults to A- Quality Assurance Feedback in the Feedback Type box with a Feedback Subtype of (*). Only use A- Quality Assurance Feedback as the Feedback Type. This ensures that no point value is assigned to the edit. 3. Press Alt + O or click OK. The system adds a QA Feedback tag and leaves the block of text selected. 2

3 4. Do one of the following: If you are replacing all selected text, press Ctrl + S to insert the appropriate Standard and overwrite the selected text. If you are not replacing all selected text, press any Arrow key or click the text with your mouse to cancel the selection of the text. Press Ctrl + S to insert the appropriate Standard at the cursor position. Resolve all QA Markers within the text. Cut or copy and paste the text as required. You can move text within the QA Feedback tag, if necessary, to put it under the appropriate headings pulled in with the Standard. To move text, highlight the text, and then press Ctrl + X to cut or Ctrl + C to copy. Move the cursor to the area in the document where you want to insert the text and press Ctrl + V to paste. QA Markers must be resolved before the text is cut or copied and pasted since the system deletes all markers when text is moved. To resolve QA Markers prior to repositioning text within the Standard: 1. Press Ctrl + J to jump to the marker, listen, and fill in as appropriate. All changes made to the document must be tracked in the document to provide QA Feedback to the MT. 2. Place the cursor at the end of the first feedback tag. 3. Press Ctrl + /. The cursor defaults to A- Quality Assurance Feedback in the Feedback Type box with a Feedback Subtype of (*). Only use A- Quality Assurance Feedback as the Feedback Type. This ensures that no point value is assigned to the edit. 4. Press Alt + M or click Comments and enter a reason for the tag in the Comments box (Old text: QA marker; New text: xxxxxx). 5. Press Alt + O or click OK. Do not insert any text in the additional QA Feedback tag. The correction is made in the original text. 6. Repeat steps 2 to 5 to add feedback for additional resolved QA Markers. 7. Once you resolve all QA Markers and give appropriate feedback, use the cut or copy and paste technique to move the text. To make additional edits within text marked with a QA Feedback tag for a Standard, such as a word that needs correction, refer to Working with Nested Feedback. To insert a Standard that affects the entire report: 1. Press Ctrl + A to highlight the entire report. The cursor defaults to A- Quality Assurance Feedback in the Feedback Type box with a Feedback Subtype of (*). Only use A- Quality Assurance Feedback as the Feedback Type. This ensures that no point value is assigned to the edit. 3. Press Alt + O or click OK. The system adds a feedback tag and leaves all the text in the selected report. 4. Do one of the following: If you are replacing all selected text, press Ctrl + S to insert the appropriate Standard and overwrite the selected text. If you are not replacing all selected text, press any Arrow key or click the text with your mouse to cancel the selection of the text. Press Ctrl + S to insert the appropriate Standard at the cursor position. Resolve all QA Markers within the text. Cut or copy and paste the text as required. Place the entire report under one QA Feedback tag only when no other option is available. It is much better to highlight/edit smaller chunks of text, if possible, so that the MT can easily see the old text and new text corrections. It is difficult to detect the changes when an entire report is crossed out at once. Follow the instructions for resolving QA Markers prior to moving blocks of text within the report. To make additional edits within text marked with a QA Feedback tag for a Standard, such as a word that needs correction, refer to Working with Nested Feedback. 3

4 WORKING WITH NESTED FEEDBACK While performing QA, there might be times when you need to reformat a large selection of text that also contains additional items that need to be fixed and marked for QA Feedback within the larger selection. This is referred to as nesting. To leave QA Feedback for all edits, follow the steps below: 1. Highlight the text associated with the larger, more encompassing correction. 3. Press Alt + O or click OK. 4. Edit the text in the selected section. 5. To make the next edit, place your cursor at the end of the first QA Feedback tag. 6. Press Ctrl + /. 7. Press Alt + M or click Comments and enter a reason for the QA Feedback tag in the Comments box. Include the original text the MT entered for reference. Do not insert any text in the additional QA Feedback tag. The correction is made in the original text. 8. Press Alt + O or click OK. 9. Repeat steps 5 to 8 to add QA Feedback for additional edits applied to the text within the first QA Feedback tag. Scenario: In the following example, the physical exam was typed in paragraph format, but should have been typed in stacked left justified format. In addition to this formatting issue, dictation was omitted and an incorrect word was used in the text. 1. Highlight all the text that needs to be reformatted. In this example, select the entire physical exam so you have access to all the text to be reformatted. 4

5 3. Press Alt + P to access the Client Profile box and enter the reason for the edit. 4. Press Alt + O or click OK to insert the QA Feedback tag. 5. Press any Arrow key or click the text with your mouse to cancel the selection of text so it is not deleted and reformat the text as follows: Scenario Part 2: For the next part of the example, "no rash" was dictated as part of the skin examination but was omitted from the transcription. Since you cannot insert a QA Feedback tag within a QA Feedback tag (referred to as nested feedback), you need to create an additional QA Feedback tag outside of the existing tag to provide feedback to the MT for this edit. You should also enter a reason for the edit in the Comments section because the system does not display Old Text/New Text for additional tags. 1. Begin by placing the cursor at the end of the first QA Feedback tag (Q#1.1). 3. Press Alt + M to access the Comments box and enter No rash (omitted dictation) as the reason for the tag. 4. Press Alt + O or click OK to insert the additional QA Feedback tag. Do not insert any text in the additional QA Feedback tag. The correction is made in the original text. The following displays the addition of "No rash" after the SKIN heading and the added Q#2.1 feedback tag: 5

6 Scenario Part 3: In the last part of the example, there was an incorrect English word within the physical exam; "not" was entered instead of "slightly." 1. Begin by placing the cursor after the last added feedback tag (Q#2.1). 3. Press Alt + M to access the Comments box and enter Old text: Thyroid is smooth and not enlarged. New text: Thyroid is smooth and slightly enlarged as the reason for the tag. Save time by highlighting the inaccurate text Thyroid is smooth and not enlarged and press Ctrl + C to copy. Next, press Alt + M to access the Comments box, type Old Text: and then press Ctrl + V to paste. Enter New Text as appropriate. 4. Press Alt + O or click OK for the system to add the QA Feedback tag. Do not insert any text in the additional QA Feedback tag. The correction is made in the original text. The following displays the "Thyroid is smooth and slightly enlarged" correction along with the added Q#3.1 feedback tag: 6