COR is an acceptable heading for Heart/Cardiovascular.
Posted By: Stands for Coronary. (NM) on 2008-11-20
In Reply to: I should know this but I need help - michelle
Subject: COR is an acceptable heading for Heart/Cardiovascular.
x
Complete Discussion Below:  marks the location of current message within thread
The messages you are viewing
are archived/old.
To view latest messages and participate in discussions, select
the boards given in left menu
Other related messages found in our database
Not saying COR as a heading? for heart exam etc? nm
Subject: Not saying COR as a heading? for heart exam etc? nm
how about typing Past Medical History heading and then typing what he says under the heading nm
Subject: how about typing Past Medical History heading and then typing what he says under the heading nm
xx
isn't it suppose to be about cardiovascular?
Subject: isn't it suppose to be about cardiovascular?
cardiovascular exam
Subject: cardiovascular exam
Distant heart sounds. There is no S3 or S4 that I can appreciate at the time of my exam. He is not short of breath either. There are no s/l wisps or hues .
The patient does have a history of heart problems including afib, coronary artery occlusive disease, ischemic cardiomyopathy, stents, etc.
it's ASCVD - arteriosclerotic cardiovascular ds.
Subject: it's ASCVD - arteriosclerotic cardiovascular ds.
or atherosclerotic cardiovascular ds...both correct
Subject: or atherosclerotic cardiovascular ds...both correct
ASCVD - my mother died of that and states this on her death certificate
? eructating nausea. ........ Cardiovascular:
Subject: ? eructating nausea. ........ Cardiovascular:
pediatric cardiovascular help needed please
Subject: pediatric cardiovascular help needed please
In the history, the doc dictates "We initially saw this young man with an episode of **sid-nims-corrhea** in 2003. There is nothing else to help me figure this out, and I have tried multiple spellings. He is a very clear doctor most of the time, but I am totally stumped. Any guidance would be greatly appreciated!
Could it be Labetalol (Trandate) for Cardiovascular
Subject: Could it be Labetalol (Trandate) for Cardiovascular
system and hypertension?
Cardiovascular: No S3, ??rev, or early systole
Subject: Cardiovascular: No S3, ??rev, or early systole
Anyone know if its REV, rev, RAV, rav, etc.. Can't figure it out.
maybe HTN? (hypertension) with hypertensive cardiovascular disease
Subject: maybe HTN? (hypertension) with hypertensive cardiovascular disease
Cardiovascular problem signs include swelling
Subject: Cardiovascular problem signs include swelling
x
I found Ashman beats in Stedman's Cardiovascular Words (NM)
Subject: I found Ashman beats in Stedman's Cardiovascular Words (NM)
x
Stedman's Cardiovascular has words hyphenated, hope this helps! Nm
Subject: Stedman's Cardiovascular has words hyphenated, hope this helps! Nm
nm
Is it a cardiac patient? CVICU (Cardiovascular Intensive Care Unit?)
Subject: Is it a cardiac patient? CVICU (Cardiovascular Intensive Care Unit?)
Word help Constitutional, eyes, ears, nose, throat, cardiovascular, s/l *tory. This is 12-point ros
Subject: Word help Constitutional, eyes, ears, nose, throat, cardiovascular, s/l *tory. This is 12-point ros
cor is the heading. sm
Subject: cor is the heading. sm
Some say Cardiac: S1 S2 etc. Some say COR: which means heart. They are just using that heading instead of CARDIAC, HEART,etc.
What heading would you use?
Subject: What heading would you use?
Okay to add headings on OP report. MD states: "Staples for skin" in the upper area with diagnoses, complications, condition....
Thanks.
Under what heading would you SM
Subject: Under what heading would you SM
put inguinal hernia in a PE? Would it be abdomen?
TIA
EKG can be a Heading
Subject: EKG can be a Heading
I would put under EKG alone as
EKG: EKG today show no ST wave changes.
Heading?
Subject: Heading?
This is for a psych. consult. After saying "New paragraph", he says "Review of past medical records." and then launches into: Doctor diagnosed tachycardia..etc.
I haven't seen a consult. with a heading, main or sub, with Review of Past Medical Records. Past Medical History, yes, but not the other. Any ideas?
Sorry, but either is acceptable
nm
either way is acceptable ....
Subject: either way is acceptable ....
AAMT prefers not making name possessive but a possessive form is acceptable if dictated or prefered by doctor. If it sounds better I would use 'S.
Yes, it is acceptable.
Subject: Yes, it is acceptable.
x
Both are acceptable and..
Subject: Both are acceptable and..
this account wants the "k". Thx
perhaps both are acceptable--sm
Subject: perhaps both are acceptable--sm
Caesarean section
From Wikipedia, the free encyclopedia
(Redirected from Caesarian section)
Jump to: navigation, search
A caesarean section (AE cesarean section), or c-section, is a form of childbirth in which a surgical incision is made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies. It is usually performed when a vaginal delivery would put the baby's or mother's life at risk, although in the last decade it has been performed upon request.
q.a.c. is acceptable.....
Subject: q.a.c. is acceptable.....
acceptable
Subject: acceptable
I would think 3 in 1 or 3-in-1 are both acceptable
Subject: I would think 3 in 1 or 3-in-1 are both acceptable
Per BOS, this is acceptable but not
Subject: Per BOS, this is acceptable but not
preferred unless specifically indicated by the client. If not specified on account specifics, I would adhere to the BOS recommendations.
Either way is acceptable...
Subject: Either way is acceptable...
Use whatever your account prefers.
2+ is acceptable. nm
Subject: 2+ is acceptable. nm
x
Either one is acceptable
Subject: Either one is acceptable
Patella is referring to the kneecap and patellar simply means relating to the patella. I just use the one that sounds the best in context with the sentence.
are both acceptable?
Subject: are both acceptable?
I had QA send back a note changing paraesthesias to paresthesias. I thought both were acceptable. I have typed it with an 'a' for years. (like orthopedic versus orthopaedic) I have never had any doctor tell me he/she prefers it without the 'a.' Thanks.
Oops, used same heading, need help
Subject: Oops, used same heading, need help
Sterile vaginal exam of 3 cm dilatation, 50% s/l "patient moderest through eustachian".
Thanks
IV abbreviated in heading
Subject: IV abbreviated in heading
Can IV FLUIDS be a heading or does it need to be INTRAVENOUS FLUIDS per the BOS?
under abdomen heading
Subject: under abdomen heading
s/l "the PICC was created" or "the tic was created"
Angie
Is it in the heading or in a sentence?
Subject: Is it in the heading or in a sentence?
I wouldn't change it in the heading, but if it sounds awkward in the sentence and your client doesn't want verbatim....
Thanks! But which book under what heading? I tried with
Subject: Thanks! But which book under what heading? I tried with
s
I think doc left heading out sm
Subject: I think doc left heading out sm
He dictates, "Skull does reveal evidence of hydrocephalus with enlarged cranium. Asymmetrical, moving equally with respiration. HEART: PMI could not be localized. S1 and S2, distant heart sounds. No S3 gallop. No murmur. LUNGS: Clinically clear.
What would be asymmetrical here?
I would put it under a heading of NECK. sm
Subject: I would put it under a heading of NECK. sm
One of the tests for meningitis is to bend your chin to your chest or to your shoulders. So if the pateint can to this, they have no meningeal signs or meningismus.
MUSCULOSKELETAL heading?
Subject: MUSCULOSKELETAL heading?
Newbie here. I'm typing an H&P and under instruction to supply appropriate headings & subheadings if they are not dictated, esp. in an H&P.
Under the Physical Examination, the Dr. dictated most headings, but under ABDOMEN, she continued with what I think is more of a musculoskeletal exam:
ABDOMEN: His abdomen is rotund, nontender, nondistended, and soft. He has no costovertebral angle (CVA) tenderness to percussion. He has no thoracic tenderness to palpation. His pain begins at approximately L2 down to his sacrum, with pain greater down his right gluteus versus his left, but does have pain. He has slow movement and grimaces with any movement. He is able to stand. Decreased range of motion secondary to pain. Straight-leg reflex painful in both legs. Reflexes are diminished bilaterally.
Here is my question: I cannot find a precedent for adding the MUSCULOSKELETAL subheading. Yet beginning from "His pain" and following is not really under an ABDOMEN exam, is it? At the very least, I feel I should start a new paragraph, but then my format is messed up b/c everything else has a subheading!
Needless to say, it stresses me out a bit. Any advice is definitely appreciated!
A lot of facilities use the heading
Subject: A lot of facilities use the heading
"laboratory" or "laboratory data" to include labs, EKGs, radiology, etc.
what PE heading would you put pilonidal under?
Subject: what PE heading would you put pilonidal under?
Just wondering under what physical exam heading other MTs put this finding under.
TIA!
No it is definetly not a heading.
Subject: No it is definetly not a heading.
I believe he is trying to say bladder urine was obtained. It could be his mis-spoke. I just wasn't sure. Thanks for your help.
A doctor can put in any heading they
Subject: A doctor can put in any heading they
want. I would use it and go on.
Followup as heading?
Subject: Followup as heading?
I'm embarrassed to have to ask this, but as a heading, which is correct--followup, follow-up, or follow up?
Per my AAMT BOS, gm is acceptable, sm
Subject: Per my AAMT BOS, gm is acceptable, sm
but g is the referred method (no period), which is the way I type it, i.e. Valtrex 1 g
Of course, my BOS is not the newest version, so things could have changed.
I think both ways are acceptable, but I would not
Subject: I think both ways are acceptable, but I would not
Either do May 10 or May 10th, but do not assume this means the current year. My 2 cents, for what it is worth.. LOL
Per BOS, subcu acceptable.
Subject: Per BOS, subcu acceptable.
zzzzzzzzzzzzzzzzzzzzzzzz
HbA1c is acceptable
Subject: HbA1c is acceptable
Substituting blood pressure with BP when it is dictated as "blood pressure" is not acceptable. That would be considered an error. Why would you use an acronym when it is not dictated as one? Every extra character helps.
|
