Unusual clinical history...
Posted By: RadGuy on 2005-11-21
In Reply to:
"The patient is status post gunshot wound to the head now complaining of headaches." Yes, bullets tend to cause headaches, I'm sure!
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At my clinical sites,...sm
the physicians' handwritten orders are transcribed by the unit clerk into the MAR (medication administration record), or if they are using Meditech they get transcribed into Meditech, again by the unit clerk. Nurses are very savvy on drugs and doses and are expected to question anything that is, well, questionable. A nurse is liable for administering the wrong drug even if the doc ordered it wrong. Both clinical sites I have been at so far were Magnet status - that is a hospital that has undergone extensive credentialing to show superior nursing care. Magnet hospitals have the lowest nurse:patient ratio, which has been directly linked with less deaths and better patient care... just my two cents.
Clinical depression
You better believe depression is real! It exists in my family and among my closest friends, and it is a painful and frustrating disease. Diabetes is often used as an analogy to compare to depression. I think it is a good one because a) diabetes is a real illness and no amount of "sucking it up" will help the body produce insulin, b) it can be treated with medication but not usually cured, and c) lifestyle adjustments coupled with medication help most diabetics feel better and function well. The same are true of depression.
Have you checked into a local county/city community services organization? There should be something available that charges fees according to your income. You need not be on welfare or Medicaid to be eligible. Go through the local government pages of your phone book and see. Call any social services type number and they can put you in touch with what you need.
Are you able to consider borrowing money from someone for a short time? Once you are under treatment you will certainly be able to pay it back quickly as you have all kinds of ability to make a living; it is just that your illness has made you disabled currently.
Also, please try to talk to someone sympathetic personally. The human touch of personal contact is so superior to what can be offered on-line. You could tell them what you have said here, or if that seems to be too strenuous, print out your post here and show it to someone, let them read it. It might break the ice and allow you to feel more comfortable speaking to them about it. The person you talk to need not be the one with the answers, right now they need to be the one who will listen and encourage you.
Many of us will continue to listen here as well, but you really need a live person in front of you to open up to at some point. It really will help, if you can do it.
My thoughts and prayers are with you for your success in treating this awful disease.
Beats my clinical setting..
I'm shut off in a 12 X 12 room, hearing loud voices outside my door, file clerks running around hunting charts and griping every minute, nurses flitting about hunting "stuff", the office manager laughing loudly outside my door while she flirts with the doctors, and my WeatherBug is calling for the heat index of 115 for my area! I'll trade with YOU!
I am on XANAX. I did not think my clinical diagnosis would be on report.
When given this diagnosis, the first thing you want to know is how far it has spread. It can mean life or death. My doctor was OOT for two more days and I was panicking. I needed to know if it was abnormal so I could begin thinking of what the future held. I am not thinking RATIONALLY!!!!!
billing on clinical psych narratives
I am an IC and am being asked to give a quote on transcribing some narrative/office notes, etc for a clinical psychologists office. In detail, it is a 1" margin around the page and there are headings on a template that you fill in either one word phrases or paragraphs. It did not look that difficult. I would have to pick up tapes, e-mail reports back on a daily basis an so I believe that gas and time doing so needs to be counted in. I am needing some advice on how to propose either by the line (gross or otherwise) or page (either full or half etc). Any advice would be greatly appreciated. Thanks in advance. 
I am outspoken and not shy but after 30 years in a clinical setting, I LOVE being by myself. nm
:?
Clinical versus Acute Care - why do companies
advertise for clinical MTs and then send you a test for acute care? I was told it was the only tests they had. I've been down this road before. Once you pass the test they place you on acute care and come up with excuses about clinical. Sooner or later they'll get the hint - when MTs apply for clinical that is what they want to type. No more testing for acute care for me - when I apply for clinical.
This is not unusual
It is not an usual side effect to lose hair after anethesia. However, major surgery can also set off other problems, such as hypothyroidism, which is also notorious for hair loss. If I were you, I would see my PCP and get some routine labs checked, just in case.
Because it is unusual...
She has every right to question it.
unusual
I want to know if this ever happened to anyone's file. This appeared in the middle of an office note
!اط��考اا��ا֝考طط��ط֝屸ほ(ᮁ���鏅ᩱ䛆��[1]شض��考طط��ط֝考طط��ط֝屸ほ(᭘���鏅ᩱ䛆��!طٓ�CE NOTE 5/24/08
Is this unusual or am I not alone?
I have had the strangest thing happen to me about how my MT career is going. Up until about a year ago, I felt very secure in my career, working for a hospital for a long time. After they let our incentive go, I got into a couple of jobs with services where it seemed like something was wrong with each. Line counts not right, no work available, etc. I finally am working as an IC with a decent company, however, when I first started there they were running out of work constantly. So, I have 3 accounts now, and I see they are hiring again.
My problem is this: I have this fear that I will never again be able to feel comfortable in my job. I keep looking for other jobs to go alongside this one in case we run out of work again. But, my doc says one job is enough, or I get stressed out. This is ever since the last year when I was tossed about between services. But I keep looking to see if I can find that 1 job where I don't have to worry anymore. I would take it along side this for long enough to know that this other new job would provide the security I seek.
Yet, when I get a second job, I am afraid of having 2, so I stick with the IC and regret that I did not try. Any suggestions? I am not asking for a million dollars, or even a guarantee that the job be 100% perfect. I just want to be comfortable in the knowledge that I can have a decent paycheck and feed my kids without worrying from day to day will there be work? Are they over-hiring again? Should I indeed quit looking for that job and settle with my phobias, or should I trust my instinct, keep looking and finally overlap the 2 for a while (in spite of the doc's warnings of stress) and perhaps get a better job?
Thanks in advance for your comments. I am so confused, because I have never in my life experienced such a lack of trust in my job and a possible new job.
Unusual names
I feel your pain, but they don't have to be foreign. What about Dakota? Is that a boy, a girl or the family truck? I know I shouldn't laugh. A dear friend has a lovely little boy with that name. It's just that when you're typing a report without a genital exam, how can you tell?
I used to be director of medical records in a tiny rural hospital, so I typed up the birth certificates. Here are some of my all-time personal favorites:
Caboose. A little boy, the 8th child. Mom didn't care what the Pope said, this was it and she had a tubal.
Princess Leia. The original Star Wars had just come out.
Vagina. Yeah, you read that right! A little girl. Nobody could change mom's mind. That was an interesting call from the Health Department!
Bambi. I know, it's more common than I thought. Great for a little kid who can't talk yet, but I have no picture of her 98 and in a nursing home.
Actually, my coworkers weren't any better. We threatened to provide a "name your baby service" for the parents who just couldn't come up with a name after 8-9 months of thinking about it. The Wolf twins were going to be Timber and Gray. The Fruit triplets were going to be Grape, Passion and Juicy. No, we never really did that, but we were tempted.
Hope you had a good laugh. You deserve it!
Bruce's Unusual Typing Wizard
Fun way to learn to type and brush up on your skills.
Doc's mispronounce all the time. This is not unusual. The reason sm
they pay us what the do is so that we insert the correct spelling and know what they are saying. You'll get better at this with experience.
Unusual word turned simple.
I just started work in a hospital and this doc, a Chinese gynecologist who is MY DOCTOR, was saying "peewah". I finally realized, it was "period"! Good heavens, I thought I was losing it and was going to have to find a new doctor in the process. I love him, but that word was making me crazy.(period or peewah, whatever you prefer) Zoinks!
What's your problem? The OP said her docs transcribe. That is unusual.
xxx
unusual for me too, worried too, not Amherst office nor Ohio
Does not sound like $$ problems, just that they do not want to pay every 2 weeks. Unusual for billi
x
Yes, ergonomic...geez, didn't think it was that unusual to say split. lol
nm
It's not unusual for a patient listed as allergic to penicillin to be given it anyway.
Often it's the only drug that will work and the allergy was vague and from so long ago, they deliberately try it anyway. If that had been the case, you'd have more than likely gotten a very negative response.
My doctor just gave me a very unusual patient name and didn't spell it,
then she's trying to read the date of discharge and says, "God, can't anybody write? You're going to have hold off on that because I really can't read any of this."
Hmmm, doc, it's just like YOUR DICTATION.....couldn't you at least spell the name or say it twice the SAME WAY within 2 sentences.
Okay, I'm done venting now.
MT is history.
After doing this for 10 years, 3+ in house, I'm on the brink of hanging it up and forgetting it. The pay keeps getting worse for the MTs (and better for the corporatists), the platforms keep getting slower and more cumbersome, the quality of the dictation does not get any better and tends to get worse overall as the old masters of English retire and more ESLs move in to replace them.
I would strongly advise anyone who is young enough to find something with a future.
CPL History
Just a thought here. It seems we're all so consumed with making lines and working faster and faster, has anyone stopped to wonder about how the 8-10 cpl rate was devised?? It seems that with the amazing fund of knowledge we have to possess to function in this profession, I feel ridiculously underpaid and overworked. The companies are constantly begging for us to do extra work with no incentives - just the statement that "here's a chance to get extra lines". I realize that this is a production-based business, but COME ON!! Am I the only one who feels like the companies are profiting big-time from our skill and knowledge?? There's so much we have to know as well -- A&P, meds, extensive terminology, hardware, equipment, and on and on. Please tell me if I'm overlooking something obvious, because I'm getting really burned out. Thanks guys for listening.
Nothing like making up history
There are in fact many Hispanics who died and continue to die for this country. I am the daughter of a WWII veteran whose mail was confiscated because he wrote letters to his mother in Spanish. While my dad was literate in both English and Spanish, his mother could only read in Spanish, as was the primary language of New Mexico, Colorado, etc. 50+ years before the Mayflower landed. Also, my brother is a Sgt.Major who retired after 25 years in the army and 3 of his sons are also currently in the army (including Iraq). But as I said before, you can ignore all that 'cause you make up your own history....and telling Native Americans to get over it only displays your ignorance.
Learn from history
and think very carefully about this person and his sob story. Boo hoo!
His child is cruel toward animals, chances are this child is being mistreated in some way by someone. This is a red flag that something in not right in this child's life regarding the adults. Children are NOT naturally violent--it is learned behavior.
Be friendly, but takes things very, very slow and think of the safety of yourself, your children, and your pet (s). Better safe than sorry.
Click on history
It states that in Nov. 2004 Warburg Pincus and Soros Private Equity Partners acquired Spheris. It is right on their history page.
Family history
You bring up a great question. Personally, I don't think any of that is their business - it doesn't affect how they will educate their child. I would not answer any of that - just put family medical history unknown.
Where do you live? I have taught in 3 states and none of the school districts I taught in, or the private school where I worked, asked.
You know, in this country it is illegal to ask someone for their national origin - how can they get by with asking about such personal information as your family Hx?
This patient with a history of
Aids is status post Pneumocystis carinii pneumonia.
Criminal History?
Can a person with a criminal history, felonies within the last 7 years, still work as an MT?
Chucky, you're history
k
You want the history of how a line is defined?
I have a feeling you're going to need it.
Sheet of paper = 8-1/2 x 11 inches.
Courier font = 10 Keystrokes per inch
Type in Courier font from the left edge to the right edge (no margins) and you'll get 85 keystrokes. Create 1" margins on left and right side and you deduct 10 keystrokes per side. Therefore, 85 keystrokes less 10 keystrokes for left margin and 10 keystrokes for right margin leaves you 65 keystrokes a 1" left margin to a 1" right margin. That is considered a "real line," as opposed to a gross line where "anything on a line is a line." It doesn't matter if you type a whole sentence or just word. If it's on a line, it's counted as a line.
When we started using computers, people switched from Courier font to other fonts, but Times Roman 12 pt was the favored. So, to calculate a line when it's not running from left margin to right margin (Times Roman 12 pt is a smaller font than Courier (see below), you simply follow the rule: 65 keystrokes equals a line. This way, it doesn't matter what font you use, you're rate of pay will be the same. So, if you're getting 6 cents a line for a 65 char line (presuming that includes spaces), you'll be paid the same no matter if your font is:
My dog has fleas and he scratches his head. (Arial)
My dog has fleas and he scratches his head. (Courier)
My dog has fleas and he scratches his head. (Times Roman)
My dog has fleas and he scratches his head. (Verdana)
All of the lines are different lengths, but you will be paid the same no matter which font you use. You don't have to worry if the person who hires you wants you to use Gothic (huge font) and Mary Contrary to use Arial Narrow (very thin font). You will both be paid the same - 65 char/line.
You also need to do is find out if spaces are included. If spaces are included then every KEYSTROKE is counted. If not, then only what you actually see (the letters) are counted. So, be sure to ask if spaces are included.
But, as far as getting 6 cents for a 65-char line ... I'm going to presume you're new to the business (what they call a newbie). As such, 6 cents per line is decent. Just make sure you get raises over time.
However, if you have at least 2 years of experience doing acute care and they offered you 6 cents per line, you really should refuse the offer ... unless it's either that or the bread lines.
AI - I think Elliott is history tonight-NM
NM
"No history of TB exposure"? nm
x
I agree with AnnuderMT because of the history....sm
of professional abuse suffered by the original poster...I mean, this young woman who has worked for such an indifferent company for 10 years without even any benefits....GEEZ! Even in these hard times, her professional skills and personal integrity are worth more than that. For heaven's sake get another job! There are still better jobs out there. If it were not for my extremely painful lower back, I'd find some PT work to do, just to keep my hand in, and even a retired MT could surely find a job with say, Medquist or some huge MTSO like that. I know what it's like to have one's professional self-esteem eroded and destroyed. Not worth it, not at all. Exit ASAP!
Any tip less than $1 is considered a cheap slight nowadays, and that is just for a piece of pie!
Interesting history of Christmas Trees
Christmas Trees
How it All Got Started | Trees Around the World | Rockefeller Center
Related Links | Tree Trivia
How it All Got Started
Long before the advent of Christianity, plants and trees that remained green all year had a special meaning for people in the winter. Just as people today decorate their homes during the festive season with pine, spruce, and fir trees, ancient peoples hung evergreen boughs over their doors and windows. In many countries it was believed that evergreens would keep away witches, ghosts, evil spirits, and illness.
In the Northern hemisphere, the shortest day and longest night of the year falls on December 21 or December 22 and is called the winter solstice. Many ancient people believed that the sun was a god and that winter came every year because the sun god had become sick and weak. They celebrated the solstice because it meant that at last the sun god would begin to get well. Evergreen boughs reminded them of all the green plants that would grow again when the sun god was strong and summer would return.
The ancient Egyptians worshipped a god called Ra, who had the head of a hawk and wore the sun as a blazing disk in his crown. At the solstice, when Ra began to recover from the illness, the Egyptians filled their homes with green palm rushes which symbolized for them the triumph of life over death.
Early Romans marked the solstice with a feast called the Saturnalia in honor of Saturn, the god of agriculture. The Romans knew that the solstice meant that soon farms and orchards would be green and fruitful. To mark the occasion, they decorated their homes and temples with evergreen boughs.
In Northern Europe the mysterious Druids, the priests of the ancient Celts, also decorated their temples with evergreen boughs as a symbol of everlasting life. The fierce Vikings in Scandinavia thought that evergreens were the special plant of the sun god, Balder.
Germany is credited with starting the Christmas tree tradition as we now know it in the 16th century when devout Christians brought decorated trees into their homes. Some built Christmas pyramids of wood and decorated them with evergreens and candles if wood was scarce. It is a widely held belief that Martin Luther, the 16th-century Protestant reformer, first added lighted candles to a tree. Walking toward his home one winter evening, composing a sermon, he was awed by the brilliance of stars twinkling amidst evergreens. To recapture the scene for his family, he erected a tree in the main room and wired its branches with lighted candles.
Most 19th-century Americans found Christmas trees an oddity. The first record of one being on display was in the 1830s by the German settlers of Pennsylvania, although trees had been a tradition in many German homes much earlier. The Pennsylvania German settlements had community trees as early as 1747. But, as late as the 1840s Christmas trees were seen as pagan symbols and not accepted by most Americans.
It is not surprising that, like many other festive Christmas customs, the tree was adopted so late in America. To the New England Puritans, Christmas was sacred. The pilgrims's second governor, William Bradford, wrote that he tried hard to stamp out "pagan mockery" of the observance, penalizing any frivolity. The influential Oliver Cromwell preached against "the heathen traditions" of Christmas carols, decorated trees, and any joyful expression that desecrated "that sacred event." In 1659, the General Court of Massachusetts enacted a law making any observance of December 25 (other than a church service) a penal offense; people were fined for hanging decorations. That stern solemnity continued until the 19th century, when the influx of German and Irish immigrants undermined the Puritan legacy.
In 1846, the popular royals, Queen Victoria and her German Prince, Albert, were sketched in the Illustrated London News standing with their children around a Christmas tree. Unlike the previous royal family, Victoria was very popular with her subjects, and what was done at court immediately became fashionable—not only in Britain, but with fashion-conscious East Coast American Society. The Christmas tree had arrived.
By the 1890s Christmas ornaments were arriving from Germany and Christmas tree popularity was on the rise around the U.S. It was noted that Europeans used small trees about four feet in height, while Americans liked their Christmas trees to reach from floor to ceiling.
The early 20th century saw Americans decorating their trees mainly with homemade ornaments, while the German-American sect continued to use apples, nuts, and marzipan cookies. Popcorn joined in after being dyed bright colors and interlaced with berries and nuts. Electricity brought about Christmas lights, making it possible for Christmas trees to glow for days on end. With this, Christmas trees began to appear in town squares across the country and having a Christmas tree in the home became an American tradition.
http://www.historychannel.com/exhibits/holidays/christmas/trees.html
Allergies would be the child's own medical history sm
Not the family medical history.
As far as juvenile diabetes or similar diseases, genetically transmitted or otherwise, if the child is being taken to the ER the parents should have already been notified and be on their way. If the child's family physician is on record with the school (a legitimate request), then medical records can be sent to the ER. I still do not see any necessity of the school having anything other than the child's OWN medical history - allergies, shot records, current state of health, etc.
...The content stays the same - history, symptoms,
s
If the ESL doctor cannot understand English enough to get a history..sm
he does NOT need to be practicing medicine in the United States. I understood the OP to say that the patient was a white American female, so I assume she speaks pretty good English!
If you check the ownership history of the site
To be fair, history and other sections are composed, SM
analyzing and gathering in the process, with sometimes additional legal and political issues to consider, and the labs are mostly just read.
You're joking, right? That was WWII, read your history books.
fdfd
HEADERS....as in what? The things like HISTORY AND PHYSICAL headings?
or the heading at the top of the page that we don't type?
and do you find it a little offputting that they can't put in writing that they pay for spaces? it makes me think all is not kosher.
the history? nothing.. he is just advertising an Indian MT company and board
x
I tell a complete stranger my whole life history practically.
I'm suddenly realizing that I have isolated myself and that I have no real friends and the only adult conversation I have is with my DH. While I love by DH dearly and he is my bestest friend, sometimes you need other conversations/relationships.
Rad is dictating what is written on requisition for History is why I would have left it along.
NM
Probably old question..history and physical plural or singular?
A history and physical was done OR A history and physical were done.
27-year-old born with no past medical history
I had that the other day. Is anyone actually born with a past medical history?
No offense, but you were unaware of the history of AAMT/AHDI
I would suggest that you learn more about the history and realities of these subjects before calling for a big strike or walkout. Credibility is an issue here.
Well, Pattie, think about this. All that family medical history you happily handed over? (sm)
When that information listing family medical history ends up in numerous computer databases, you've effectively hampered your child's future ability to obtain medical insurance, life insurance, and who knows what. Although they may not know anything about the identities of parents and grandparents, they sure do know what medical predisposition insurance companies may think are just too risky to sell a policy. Think about that.
Does Dave Navarro have the biggest head in history. So out of proportion. Smart guy though.
His piercings and tattoes are somewhat distracting but........ he's okay. Bruce? Back in the day.
Crash, The Chronicles of Narnia, War of the Worlds, Derailed, A History of Violence,
Brokeback Mountain, and Dreamer. All of them were good, although I think Brokeback Mountain would be on the bottom of the list for me. Crash and The Chronicles of Narnia were very good in my opinion.
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