"imperforated anus, failed colostomy, imperforated anus, plan to do sl teeshart procedure"
Posted By: yas on 2009-06-07
In Reply to: Please give more information. What part of the body? - Olive
Subject: "imperforated anus, failed colostomy, imperforated anus, plan to do sl teeshart procedure"
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I think it should be "imperforate" anus...
Subject: I think it should be "imperforate" anus...
Differential dx: s/l anus laxus??? SM
Subject: Differential dx: s/l anus laxus??? SM
The patient had a syncopal episode.
Cecum not close to anus. Google suggested
Subject: Cecum not close to anus. Google suggested
seton.
By periodic tightening around the tissue encircled by the fistula, the cutting seton ... Use of the seton in the treatment of extrasphincteric anal fistula. ...
I would write it as "inflammation of the anus" and forget trying to decipher the EFL descripti
Subject: I would write it as "inflammation of the anus" and forget trying to decipher the EFL description
nm
candidiasis culture or anus culture? I'm just guessing here.
Subject: candidiasis culture or anus culture? I'm just guessing here.
Ever heard of a Hewitt? procedure done with a colostomy.
Subject: Ever heard of a Hewitt? procedure done with a colostomy.
Physician has in parentheses (abdominoperineal resection) but clear states
patient under went a Hewitt? and at that time a colostomy was done..
Thanks
Hartmann _______ procedure - general surgeon talking about colostomy
Subject: Hartmann _______ procedure - general surgeon talking about colostomy
He's definitely saying Hartmann's ________ procedure, and the blank sounds like "lung."
Thanks so much!
Not sure but comprehensive 65 plan, may be referring to age/healthcare plan?
Subject: Not sure but comprehensive 65 plan, may be referring to age/healthcare plan?
Sorry, tried to help. Have a nice weekend.
First one failed VBAC sm
Subject: First one failed VBAC sm
Don't know if you're required to expand dx for your account, but vaginal birth after cesarean
failed conservative treatment
Subject: failed conservative treatment
NovaSure device failed cavity
Subject: NovaSure device failed cavity
s/l a ray position. ???
TIA!!!!!
s/l failed PTAP dialysis graft
Subject: s/l failed PTAP dialysis graft
Patient with urinary incontence. Has failed s/l Premarin cream. sm
Subject: Patient with urinary incontence. Has failed s/l Premarin cream. sm
Has anyone heard of this use for Premarin cream? I've searched but can't verify. Maybe there's something that s/l Premarin that I'm missing. Thanks.
colostomy
Subject: colostomy
I actually had that surgery. It is common to have a colostomy and then six months later have it reversed or sometimes they call it a takedown. There is a cecostomy that is a fecal catheter if I am reading right so it could be either colostomy or cecostomy.
An ileal resection is the treatment, so I don't know how it was put in as part of the disease.
patient with failed back syndrome and s/l Shareet disk ?? Tried SH, CH, can't find. thx.
Subject: patient with failed back syndrome and s/l Shareet disk ?? Tried SH, CH, can't find. thx.
xx
Pt doing well following takedown of colostomy...take down??? Thx nm
Subject: Pt doing well following takedown of colostomy...take down??? Thx nm
nm
endescending colostomy?
Subject: endescending colostomy?
She blatantly says endescending colostomy, never heard it before. Any ideas?
?SP? colectomy and colostomy
Subject: ?SP? colectomy and colostomy
"She has history of stage IIIB colon cancer with ?SP? colectomy and colostomy. She is on adjuvant chemotherapy....."
Patient with failed back syndrome having an s/l Octek spinal cord stimulator.
Subject: Patient with failed back syndrome having an s/l Octek spinal cord stimulator.
I can't document anywhere. It is one of those days!!!!
bright red blood per the colostomy
should it be colostomy bag? The doc just says...no bright red blood per the colostomy.
Down syndrome child with colostomy...sm
Subject: Down syndrome child with colostomy...sm
underwent "PSARP" ? two weeks ago. Very clear, but have not been able to find.
States colostomy is health and then states that the s/l "peroneum" is well healed........should that not be peritoneum? Thanks.
**diversionary** colostomy and had *stomonecrosis**
Subject: **diversionary** colostomy and had *stomonecrosis**
Do they have a colostomy or ileostomy? Might be appliance is intact. nm
Subject: Do they have a colostomy or ileostomy? Might be appliance is intact. nm
s
end-to-side colostomy, describing the anastomosis? nm
Subject: end-to-side colostomy, describing the anastomosis? nm
s
Colostomy, but Brooke-type suture I guess. Thank
Subject: Colostomy, but Brooke-type suture I guess. Thank
x
s/l rucey procedure -- wondering if it is Ruiz procedure ...
Subject: s/l rucey procedure -- wondering if it is Ruiz procedure ...
The sentence reads "I advised the patient to undergo so-called s/l rucey procedure (i.e., bone graft repair of the nonunion)." This is an orthopaedic doctor dictating. TIA.
Gold's procedure or Gould's procedure..ortho? nm
Subject: Gold's procedure or Gould's procedure..ortho? nm
v
maybe saying something like FB syndrome or failed back surgery syndrome ?
Subject: maybe saying something like FB syndrome or failed back surgery syndrome ?
Plan
Subject: Plan
CBC with differential, type and cross for 20 units, electrolytes P3, P4, PT, PTT, EKG, PA and lateral chest pulmonary function test.
I'm just in school for Med Trans. I love this website. I'm always confused when it comes to listing labs. I need help on the above. Thank you so much.
Plan help please!
Subject: Plan help please!
 I am a new, and need some help. after the doctor says plan he lists the medications he has prescribed. He does not number them and I am used to them saying medications and then listing (1, 2, 3) Do they usual do that? Should I leave it like he says it? Example:
PLAN:
Ecotrin 1 p.o. b.i.d. with meals. Keflex 500 mg p.o. q.i.d. for 4 days.. Follow-upl with me within the next 10 days.
thanks!
Plan help please!
Subject: Plan help please!
That all depends on the QA person reviewing the report.
I have been told both are correct and both are wrong, other than if there is only one item (in which case you never number).
I have been audited and smacked down (points) for NOT numbering when the dictator did not number on meds and on diagnoses, etc., even on a verbatim account. I would love if someone could explain why. The client profile for the account says "do not number" if the dictator does not number.
Plan.... UA and CNS or C&S?? thank you
Subject: Plan.... UA and CNS or C&S?? thank you
Do you have to have a plan?
Subject: Do you have to have a plan?
Where I work, if they don't say "plan", they don't get a "plan".
That's what I plan to do.
Subject: That's what I plan to do.
I do not like to guess. Now it says for prostate cancer, so it might be. I will just flag it and put a s/l, just in case. I don't want them to think I didn't try to look it up either.
Here's another one: Under Assessment/Plan
Subject: Here's another one: Under Assessment/Plan
1. Erythrocytosis – the patient did have a hemoglobin of 17 on blood work one year ago. I asked him to repeat it, but he forgot. We will recheck his CBC with NORRIS REPREEDIN level today and work this up accordingly. He is not symptomatic.
I keep listening over and over to this, and this is all I can make out. Any clue what he might be referring to??? TIA
assessment&plan help!
Subject: assessment&plan help!
If the doctor says assessment and plan together, do I put the header together? I am confused because when he gives the assessment he numbers them 1) 2) then when he gives the plan he numbers them as well but does not say plan any help?
ASSESSMENT:
- Bilaterally arm numbness.
- Nausea.
- Health maintenance recommendations.
PLAN:
- Patient’s critical examination was hyperreflexia suspicious for possible cervical lesion. She will be referred for MRI with cervical spine. Patient may need EMG to further access her numbness.
- Patient will be tried on Nexium, although she does not have any overt symptoms of heartburn. She does have chronic nausea and this may be a sign of stomach reflux. She will be tried on Nexium 40 mg one q.d. Other diagnostic possibilities include slow gastric emptying. The patient does not eat breakfast or lunch and has her largest meal at about 8:00 at night. We discussed the need to consume breakfast and ideally eat 3-5 meals per day, smaller meals to encourage her metabolism. ___ problem health maintenance and in regards to increase her exercise and changing her diet. Patient will be referred to OB/GYN for Pap and pelvic and also will be referred for a screening mammogram. When she follows up to see me we will discuss potential options for colon screening. Patient is to follow-up with me in approximately 1 month time.
assessment and plan
Subject: assessment and plan
I hate when docs do that - mine do it a lot. I think you're good either way but I would put "A&P" as the heading and then just type it the way the doc says it.
starts plan
Subject: starts plan
it starts the plan then says ??? flonase 2 sprays each nostril
Sounds like a plan to me!!
Subject: Sounds like a plan to me!!
Thanks!!
s/l her-plan-jet-ick lesions
Subject: s/l her-plan-jet-ick lesions
s/l her-plan-jet-ick lesions in the mouth and throat
this is a 17 month old with excessive drooling and fever.
that sounds like a plan
Subject: that sounds like a plan
nm
SIMES procedure or SIMS procedure maybe?
Subject: SIMES procedure or SIMS procedure maybe?
Has anyone every heard of the Simes or Sims procedure? I never heard of it and I am having a hard time trying to verify. Perhaps I am not spelling it correctly?
Thanks!
Is this directions for something or what? A plan at the end of a scan? nm
Subject: Is this directions for something or what? A plan at the end of a scan? nm
s
In plan he very plainly says says need to rule out
Subject: In plan he very plainly says says need to rule out
Patient fell and injured right ankle. Sentence in question: She is significantly tender in the s/l coronal ligament s/l and the (or in the) right ankle.
Plan: MRI to rule out coronal ligament tear.
This is very clear - just cannot document it anywhere and don't want to flag it as it's very clear - just unsure and hoping for documentation or someone that has heard it.
Where would you begin the PLAN if the dictator does not say so?
Subject: Where would you begin the PLAN if the dictator does not say so?
ASSESSMENT: We discussed options for Jeff. At this point, a month after the injury, an MRI, potential surgical interventions, etc., ultimately doing as well as he is, he is just going to keep it in mind and be careful with his lifting. He drives a forklift, apparently on a regular basis, but we are going to forego further work up at this point. We also got int a discussion of routine health care maintenance. He will plan on complete physical in October, starting this year. I will put a standing order at lab at this point for him, for a UA basic metabolic fasting lipid panel and PSA. We will go from there.
Help with sentence. This is doc's treatment/plan: sm
Subject: Help with sentence. This is doc's treatment/plan: sm
The sentence just doesn't seem right to me. Any input appreciated!
" Examination, evaluation, simple avulsion nail plate, 3rd left lateral aspect nail plate avulsed paronychium performed under anesthesia."
Plan: Check CMP and s/l iris ads
Subject: Plan: Check CMP and s/l iris ads
In plan, doc says check s/l FH LSH. How would this be typed --
Subject: In plan, doc says check s/l FH LSH. How would this be typed --
plan of coagulation? planned? WAG
Subject: plan of coagulation? planned? WAG
ASSESMENT/PLAN COMBINED?
Subject: ASSESMENT/PLAN COMBINED?
WHen doing a SOAP NOTE
Can you Combine Assessment/Plan or are you supposed to seperate?
Even if doctor doesn't dictate a new paragraph? Thanks!
Thanks!!! no he says pila plan but cant find that--see more
Subject: Thanks!!! no he says pila plan but cant find that--see more
he diagnosed condition as blepheritis so that will work. thank you!!!!!
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