Assessment or Impression
Posted By: zj on 2007-05-12
In Reply to:
Is it an AAMT rule to automatically number the diagnoses in the Assessment or Impression of an H&P or soap even if the dictator does not? TIA!
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Help with IMPRESSION
Subject: Help with IMPRESSION
Should this be dictated like this?
1. Hyponatremia, rule out subdural hematoma.
OR
1. Hyponatremia.
2. Rule out subdural hematoma.
impression
Subject: impression
type it with a semicolon in between.
Impression
Subject: Impression
Hi Shirl -
Hang in there, this will be old hat to you after a while. Radiology reports are usually pretty standard. Same phrases/terms used by all radiologists.
Some usual headings in a radiology report are:
CLINICAL INDICATION: or INFORMATION: or HISTORY, or variations of any of these.
FINDINGS: or RESULTS:
IMPRESSION: or OPINION:
Start adding the common phrases, like "lung markings" and all the various possible headers as above, to whatever word expander program you have. You'll be flying through reports in no time!
Impression
Subject: Impression
In the impression the doctor says the patient probably has a small perforation of his colonic cancer.
Impression
Subject: Impression
Status post laceration, rigth wrist with repair of partial tear to the s/l FC or FCE tendon.
Assessment
Subject: Assessment
ASSESSMENT: Family history of AAA. Will proceed with -- s/l "root" ----- to evaluate.
Anyone have any idea what this is?? I'm drawing a blank.
TY!!
Help with assessment
Subject: Help with assessment
Hypertension with s/l "realciaporosis"...??
Any ideas??
TIA 
assessment ?
Subject: assessment ?
Patient had an s/l EIP - EPL transfer.
in the assessment i would, otherwise no
Subject: in the assessment i would, otherwise no
Assessment ?
Subject: Assessment ?
Assessment ?
Subject: Assessment ?
Can you have an abbreviation like URI in an assessment? Thx. Tina
Assessment
Subject: Assessment
Thank you for the assessment info!!
she may say it again in impression if you haven't got there. nm
Subject: she may say it again in impression if you haven't got there. nm
IMPRESSION prob
Subject: IMPRESSION prob
I have a problem under impression  ...
"D: IMPRESSION: Occipital neuralgia probable acute gastroenteritis"
question: how will I transcribe that? coz Occipital neuralgia is not related to "probable acute gastroenteritis" isn't it? or possibly there was a 2 impression. one, is occipital neuralgia and secondly, acute gastroenteritis?... What's the meaning by the dictator?
NOTE: but the dictator did not dictate any numbering.... 
No, but it is either part of the Impression, or
Subject: No, but it is either part of the Impression, or
the a new section after it.
Thanks :)
Impression - hypertension
Subject: Impression - hypertension
This is under impression on a history and physical examination.
It is a numbered list.
[Sodiunduradine] is hypertension.
Any suggestions would be great!
It was under the impression section
Subject: It was under the impression section
I have heard of that also, but it was under his impressions. This doctor is such a mumble mouth! *sigh*
On impression: MR say pat uremeia.
Subject: On impression: MR say pat uremeia.
Pt with mental retardation.
CAGE assessment?
Subject: CAGE assessment?
CAGE Assessment (Alcohol Abuse)
Powered by:. CAGE Assessment (Alcohol Abuse). For most people who drink, alcohol
is a pleasant addition to eating and to other social activities. ...
https://www.merck.healthinkonline.com/ merckTools/AssessMerckSourceCAGE.asp - 19k - Cached - Similar pages
screening questions - CAGE assessment
Aquarius - UK Midlands charity providing advice and counselling on alcohol and
drugs problems.
www.aquarius.org.uk/cage.htm - 14k - Cached - Similar pages
Livingston County Council Alcohol & Substance Abuse - Assessment
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
It was not a test. It was the assessment.
Subject: It was not a test. It was the assessment.
nm
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.
Should EKG be expanded in Assessment?
Subject: Should EKG be expanded in Assessment?
ASSESSMENT: Abnormal EKG.
question about assessment
Subject: question about assessment
Doc states CABG and mitral valve repair. He clearly states this together. Can this be listed as one assessment? Or should mitral valve repair be next number??
pulmonary assessment
Subject: pulmonary assessment
admitted for elective mediastinoscopy, s/l radio-gram-coscopy?? and left bronchotomy.
I would not abbrev it if it is in the IMPRESSION as the poster said.
Subject: I would not abbrev it if it is in the IMPRESSION as the poster said.
it's impression and lung markings....
Subject: it's impression and lung markings....
No, not as a listed diagnosis or impression.
Subject: No, not as a listed diagnosis or impression.
impression, SP - status post
Subject: impression, SP - status post
nm
GI help: Is it diaphragmatic compression or impression
Subject: GI help: Is it diaphragmatic compression or impression
Trying to distinguish between diaphragmatic compression or diaphragm and compression or diaphragmatic impression. Help appreciated.
Ahhh...that's diaphragmatic impression. nm
Subject: Ahhh...that's diaphragmatic impression. nm
Thanks. Duh. I have to spell out abbreviations in impression. Just could not think. NM
Subject: Thanks. Duh. I have to spell out abbreviations in impression. Just could not think. NM
ss
That is the complete sentence. It is his IMPRESSION.
Subject: That is the complete sentence. It is his IMPRESSION.
Assessment: Vaginitis DX. I never heard of DX?? thanks
Subject: Assessment: Vaginitis DX. I never heard of DX?? thanks
Under assessment: UNCOMPELLING EMG results
Subject: Under assessment: UNCOMPELLING EMG results
Is uncompelling a word?
Or is it noncompelling?
Thanks!
Assessment: Dry skin (s/l ictiosis).
Subject: Assessment: Dry skin (s/l ictiosis).
:-)
Geriatric Assessment Unit
Subject: Geriatric Assessment Unit
.
Oh...assessment is diagnosis..so I would type it out nm
Subject: Oh...assessment is diagnosis..so I would type it out nm
xx
"HO" assessment (alcoholism)
Subject: "HO" assessment (alcoholism)
Has anybody ever heard "EtOH" pronounced as "aitch oh"? Or know what "HO assessment" could mean in relation to alcohol treatment?
"Patient was not eligible for HO assessment."
Thank you!
Could you post the impression? Might help to shed light. nm
Subject: Could you post the impression? Might help to shed light. nm
impression: bronchiolitis s/l sublets? or other process
Subject: impression: bronchiolitis s/l sublets? or other process
s/l ID or ID8 urine culture. for impression and plan
Subject: s/l ID or ID8 urine culture. for impression and plan
Extrinsic impression ? on the sigmoid colon
Subject: Extrinsic impression ? on the sigmoid colon
I was under the impression it was JCAH mandated to write ml instead of cc. NM
Subject: I was under the impression it was JCAH mandated to write ml instead of cc. NM
Got first one - he says in impression "flow limiting stenosis"
Subject: Got first one - he says in impression "flow limiting stenosis"
Impression: Right MPJ extensor hood rupture SM
Subject: Impression: Right MPJ extensor hood rupture SM
(s/l shrowd ligament rupture).
s/l topo or tolpol for fetal assessment
Subject: s/l topo or tolpol for fetal assessment
Hi! Need help as soon as possible. Typing history and physical for admission of a woman in labor. Here is what is dicated:
Fetal heart rate tracing is in the 140s and reassuring with good variability, accelerations, and no decelerations. (s/l topo or tolpol) is minimal if at all.
Thanks in advance!!
It is Mallampati. A classification used in ariway assessment.
Subject: It is Mallampati. A classification used in ariway assessment.
The number would be Class IV
Thanks for your reply. I will type CAM in the assessment and see what my manager says. nm
Subject: Thanks for your reply. I will type CAM in the assessment and see what my manager says. nm
nm
Assessment: s/l maseno fracture right ankle. nm
Subject: Assessment: s/l maseno fracture right ankle. nm
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