Axis format but employer prevails
Posted By: darlene on 2009-02-20
In Reply to: more on psych reports - MT
Subject: Axis format but employer prevails
I go like so
Axis I
xxxxx
xxxxx
xxxxx
Axis II
Axis III
Axis IV
Axis V
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normal axis is correct. On an EKG usually it's either rightward axis, leftward axis, or SM
Subject: normal axis is correct. On an EKG usually it's either rightward axis, leftward axis, or SM
no axis deviation which is some times dictated as "normal axis."
In Stedman's I have cephalocaudal axis aka long axis of the body.
Subject: In Stedman's I have cephalocaudal axis aka long axis of the body.
Axis I: Axis II: etc. in list form.
Subject: Axis I: Axis II: etc. in list form.
x
maybe somnolent or combatant? Can go either way, but usually sleepiness prevails. nm
Subject: maybe somnolent or combatant? Can go either way, but usually sleepiness prevails. nm
s
my employer does...
Subject: my employer does...
want them in all caps...lol. Thank you so much for the kind words, I really appreciate them. :-)
The client will most likely let you know how they want it or your employer. sm
Subject: The client will most likely let you know how they want it or your employer. sm
Apparently BOS states both ways. Ex. X-rays, 2 views, blah, blah, blah.. or X-rays, two views, blah, blah, blah.... Same would apply with 1st and first. I've had experiences where the client dictates which way they'd like it, and both are correct depending on which BOS you go by. Hope this helps.
Moron. If her employer found out she was doing that she'd
Subject: Moron. If her employer found out she was doing that she'd
lol
she's posting confidential info that her employer would
Subject: she's posting confidential info that her employer would
doesn't teach her anything but to rely on others rather than use her own qa and to find answers
she's dangerous doing that!
It's up to your employer how much leeway you have to make something "correct" and/or how mu
Subject: It's up to your employer how much leeway you have to make something "correct" and/or how much of a
s
Axis
Subject: Axis
Active range of motion is normal in all Axis? Should it be plural, and if so, how is it typed? Thanks!
Axis
Subject: Axis
Cool. That's what I thought. Thanks.
Axis
Subject: Axis
I type Axis then double space on the same line. 
Axis I-VI
Subject: Axis I-VI
"diagnoses"
format
Subject: format
No.1 PDS or #1 PDS? Which is correct?
Format ?
Subject: Format ?
5/5 strength throughout sensation is intact. So the 5/5 is not at the start of the sentence, how would you reword this phrase?
OB format for G 3, P 1-1-0-2
Subject: OB format for G 3, P 1-1-0-2
Is this how you type that? I havn't heard it transcribed that way before... Thanks!
Format Help
Subject: Format Help
How do you type the name of a book? Italics or quotations? TIA
Format help
Subject: Format help
I have a dictator who constantly repeats words, phrases, entire sentences! Do you transcribe it twice or if she has already stated it, leave it out? 
axis.......nm
Subject: axis.......nm
nm
QRS axis -43 is this always (-)??
Subject: QRS axis -43 is this always (-)??
Format ?
Subject: Format ?
Would it be MEDICATIONS: Include
1.
2.
3.
axis 1????
Subject: axis 1????
DIAGNOSES
Axis one adjustment disorder with anxiety moderate in degree.
Psychogenic amnesia.
Axis two diagnoses deferred
Axis three heart disease, pulmonary disease, hypertension. complications from steroid medication. Neuritis and cerebral frontal atrophy.
Axis? four degree of psychosocial stresses are moderate to severe due to illness within herself.
Axis?? five highest level of adaptive functioning has been fair socially, poor occupationally for at least 5 years.
by saying this is he just listing it? like should it just be.
1.
2.
3.
4. so on so on?...
Axis
Subject: Axis
Took this from a sample report:
Assessment
Axis I -- Major depression, recurrent.
Axis II -- Deferred.
Axis III -- Head injury aged three. ? post-traumatic seizure disorder. Rule out pseudoseizures.
Axis IV -- Moderately-severe psychosocial stress.
Axis V -- GAF is 55.
hope this helps would be : after each axis not those dashes
Axis IV . . . help please
Subject: Axis IV . . . help please
What does it mean when the doc says, "Axis IV: 1, 2, 3." And how would I type that.
TIA 
QRS axis? nm
Subject: QRS axis? nm
H & P Format
Subject: H & P Format
Just when I think I have it on format - I don't. The following is under PHYSICAL EXAMINATION. What would the subheading be?
Patient walks to the right occasionally. She has trouble getting started because of discomfort. She can walk on heels and toes briefly. However, on a tandem walk she really has difficulty with that. She does not line up her toes easily, loses her balance very easily with that. This is typed as dr. dictated. Suggestions would be appreciated.
Diagnosis re Axis
Subject: Diagnosis re Axis
What is the most recent rule regarding diagnosis?
Axis 1:
Axis I:
AXIS I:
Do you run the diagnosis right after axis, or begin a new left at the left margin underneath the Axis?
I am having some reports changed to:
AXIS I:
BIPOLAR DISORDER (rather than putting it on the same line as AXIS).
Thanks very much.
Abbreviation Format
Hi... Can someone tell me the correct format for what comes after this med in a dictation: "Zarontin 250 mg 500 500 250 500?" Is this 500 am, 500 mid-am, 250 afternoon, 500 bedtime?
Thanks! 
Abbreviation Format
Subject: Abbreviation Format
Thanks! I thought that would be a mega-dose as well, but that's what she said. I did "slash" them though.
format question
Subject: format question
Do you put immunizations under the Social History section in a report or by themselves? I'm not testing, just confused. The doctor is dictating: "All immunizations are up to date" under Social History. Thanks.
Format question...
Subject: Format question...
Hi, I'm wondering whether AAMT BOS says to type this: "image #31 series 3" or this: "image #31, series 3." Comma or no?
Thank you! :D
Format question
Subject: Format question
This is so small I hate to ask, but everytime I type this it just looks odd no matter what way I type it and would like to know how another MT would type this.
If someone has a dull aching sensation or sharp stabbing sensation would you hiphenate (dull-aching sensation) or slash (dull/aching sensation) or just leave it (dull aching sensation)? Thanks for any input to my "stupid" question. 
I would say cecal and S1-S2 is how I format it...nm
Subject: I would say cecal and S1-S2 is how I format it...nm
s
number format
Subject: number format
When transcribing a very large number, "1 million 120 thousand" is it considered more acceptable to use words or just to stick to numbers?
Format question
Subject: Format question
I was hoping someone might be able to give me the rule for this.....Should departments be capitalized? For instance, "she saw University of Virginia orthopedics" Should orthopedics be capitalized or not? I'm always confused about this:)
format question
Subject: format question
I was taught that if the "orthopedics" came after the name of the place, it should be capitalized (UoV Orthopedics). If not, it wouldn't be capitalized(orthopedic department at UoV). Please correct me if I'm wrong, anyone! :)
s/l capsular axis
Subject: s/l capsular axis
A capsular tension ring was placed and removal of the bulk of the lens was accomplished without evidence of capsular tear. After removal of the lens, the (s/l capsular axis) appeared to be eccentric.
Punct? format?
Subject: Punct? format?
REVIEW OF SYSTEMS
He is 6 feet tall and weighs 260 pounds. His weight has been stable. No rashes. No problems with his eyes, ears, nose or mouth. Respiratory: he is positive for a smoker, half pack per day, with a smokers cough. Cardiovascular: has a history of hypertension. No GI/GU problems. Musculoskeletal is stated in the HPI. No neurological or hematological disorders.
Is this how this should be put in paragraph form with the Respiratory and Cardiovascular??
Radiology Format ??
Subject: Radiology Format ??
DUPLEX SCAN OF LEGS
Duplex scan of the arterioles system in the legs was performed and results are as follows:
RIGHT LEG: On the right side,
Is this layout correct? or is it
RIGHT LEG no colon? then drop down a line? Thanks
Format rules in MT
Okay, I am an old gal working mostly ias in-hospital MT (VA, Teaching hospital), but I did also work off and on for MTSOs at home. Now going back a long time, I was always taught that in formatting Problem Lists or Hospital Course by problem list you transcribe it this way. Problem #1 - HYPERTENSION. The patient is taking lisinopril currently..... or if the doc did not say PROBLEM #1, then you transcribed it 1. HYPERTENSION. Blah, blah, blah. When did this change and become wrong? Most of the docs I am now transcribing for one of the major MTSOs now (left the hospital), actually ask that we capitalize the major problem. Is this in the so-called AHDI BOS2?
IMHO, using the capitalization on the problem is much easier to read, than this...
1. Hypertension. The blah, blah, blah..
2. Diabetes mellitus type 2. Uncontrolled. Not compliant.
Any QAers out there can answer this one for this old school nitpicker?
maybe "long axis" ??
Subject: maybe "long axis" ??
format that to your accts specs (sm)
Subject: format that to your accts specs (sm)
a.m., AM, whatever your acct likes! LOL
I would go with minus 2-degree axis
Subject: I would go with minus 2-degree axis
/
I was pretty sure about the axis part, but...
Subject: I was pretty sure about the axis part, but...
he slurrs his sentences all together. What about low transition LVH by voltage? I couldn't find that anywhere, not that I am even sure that is what he is saying!!!
Format for multiple problems
Subject: Format for multiple problems
Can someone show me an example of how to type a report that has multiple problems. The doctor does one problem completely, then goes onto the next one.
It doesn't look right typing HISTORY OF PRESENT ILLNESS, PHYSICAL EXAMINATION twice throughout the report.
Thanks
EKG: ADP NP (or) and P are interval normal axis.
Subject: EKG: ADP NP (or) and P are interval normal axis.
I hate abbreviations.
The only thing that shows up in my cardiology book is adenosine diphosphage, and that doesn't tell me what the next NP or and P would mean. I wish they'd just say what they mean instead of abbreviating, because if I can't figure them out I'm blanking them.
Format & Capitalization (psychiatric)
Subject: Format & Capitalization (psychiatric)
Capitalize verbal, performance, and full-scale? Should I leave the subtest scores in a vertical list arrangement or use a different format?
On this administration of the Wechsler Adult Intelligence Scale-III, Mr. ___ obtained a verbal IQ of 57 (range 53-63), a performance IQ of 64 (range 59-73), and a full-scale IQ of 56 (range 53-61). These scores fall within the mild range of mental deficiency.
The following scatter of subtest scores was obtained:
VERBAL:
Vocabulary: 2
Similarity: 3
Arithmetic: 2
Digit Span: 3
Information: 3
Comprehension: 2
PERFORMANCE:
Picture Completion: 4
Digit Symbol: 4
Block Design: 4
Matrix Reasoning: 5
Picture Arrangement: 4
All the scores above fall within the mentally deficient range and are relatively even.
ligamental axis? guessing only here....
Subject: ligamental axis? guessing only here....
Go to format/paragraph and you'll see it. nm
Subject: Go to format/paragraph and you'll see it. nm
In MSWord, go to Format, Font,..
Subject: In MSWord, go to Format, Font,..
Effects, place a check mark next to Subscript.
Just a general question on format
Subject: Just a general question on format
I have been using these forums for a while now and I keep seeing people using "nm" and "sm". What does this mean?
nm = no message
sm = see message
Just a guess
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