Could it be a heading under PE? ex: Urinary: Urine obtained from cath...
Posted By: nm on 2009-01-28
In Reply to: Urinary urine was obtained from catheter. - JuliaC
Subject: Could it be a heading under PE? ex: Urinary: Urine obtained from cath...
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Urinary urine was obtained from catheter.
Subject: Urinary urine was obtained from catheter.
Does this sound right or should the first Urinary be edited out. Thanks for any suggestions.
pt obtained CT scan- doc says s/l 10 profiles or maybe kempro files were obtained
Subject: pt obtained CT scan- doc says s/l 10 profiles or maybe kempro files were obtained
http://library.med.utah.edu/WebPath/TUTORIAL/URINE/URINE.html
Subject: http://library.med.utah.edu/WebPath/TUTORIAL/URINE/URINE.html
http://library.med.utah.edu/WebPath/TUTORIAL/URINE/URINE.html
leukocyte esterase test, urine C&S = urine culture and sensitivity
Subject: leukocyte esterase test, urine C&S = urine culture and sensitivity
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
urine cultures, GC, chlamydia, urine s/l SMV.nm
Subject: urine cultures, GC, chlamydia, urine s/l SMV.nm
xx
Whis is correct?: Port-A-Cath, port-a-cath or portacath
Subject: Whis is correct?: Port-A-Cath, port-a-cath or portacath
PORT-A-CATH® is on company site, I usually use Port-A-Cath
Subject: PORT-A-CATH® is on company site, I usually use Port-A-Cath
s/l hemostasis was obtained with
Subject: s/l hemostasis was obtained with
an osteen. Does anyone know if there is there such a thing as an O'steen or Osteen for hemostasis?
s/l hemostasis was obtained with
Subject: s/l hemostasis was obtained with
bipolar and "motor" cauterization. Could "motor" be correct?
good purchase was obtained
Subject: good purchase was obtained
orthopedics expression
say pO2 of 266 obtained on a s/l PRVC of 14, total
Subject: say pO2 of 266 obtained on a s/l PRVC of 14, total
total volume ? was 700. is this right?
opinions please attained/obtained
Subject: opinions please attained/obtained
I have a doc who keeps saying hemostasis was attained (spells it). He is ESL - I think you OBTAIN hemostasis. Am I wrong?
influenza s/l wash was obtained ???
Subject: influenza s/l wash was obtained ???
xx
Hemostasis was obtained with s/l burn wax.
Subject: Hemostasis was obtained with s/l burn wax.
Cervical procedure, s/l "on vasse" views? obtained. nm
Subject: Cervical procedure, s/l "on vasse" views? obtained. nm
s/l: Single "remedial" measurement obtained confirms size.
Subject: s/l: Single "remedial" measurement obtained confirms size.
Help...
Thank you comrades :) Bless your hearts.
Circumferential control obtained of the graft at these two sites with "posh" ligatures, and th
Subject: Circumferential control obtained of the graft at these two sites with "posh" ligatures, and then sm
the graft was clamped distally towards the arterial side, proximally towards the venous side, transected, and the intervening segment between the two incisions sewn off with two layers of 5-0 Prolene x2.
"Cervix does not slide to the pts left. Patch and vaginal cultures obtained." Is this right?
Subject: "Cervix does not slide to the pts left. Patch and vaginal cultures obtained." Is this right?
EKG obtained shows atrial fibrillation, left bundle branch block, occasional pace response.
Subject: EKG obtained shows atrial fibrillation, left bundle branch block, occasional pace response.
Urinary catheter
Subject: Urinary catheter
Dr says Couday tipped catheter was inserted with good results.
Any help on Couday or Cuday? Cannot document.
TIA
Is this for urinary tract? nm
Subject: Is this for urinary tract? nm
I think she does mean continent urinary SM
Subject: I think she does mean continent urinary SM
conduit, but she is saying incontinent urinary conduit. Thanks for your help :)
urinary urgency
Subject: urinary urgency
Patient has urinary urgency. She has a hisotry of urge incontinence. There are no side effects reported such as dry mouth or s/l f-sat-ic symptoms.
Thanks
Penim? urinary... thanks!
Subject: Penim? urinary... thanks!
xx
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?
Would help to know what it's for. GI, urinary or cerebral palsy, etc. nm
Subject: Would help to know what it's for. GI, urinary or cerebral palsy, etc. nm
Procedure for urinary incontinence...
Subject: Procedure for urinary incontinence...
Monarch? Monarc? Thanks!
"imipramine" is sometimes used for urinary incontinence ./nm
Subject: "imipramine" is sometimes used for urinary incontinence ./nm
.
Uristat. Urinary analgesic. sm
Subject: Uristat. Urinary analgesic. sm
It is phenazopyridine. Also in that line are Azo-Standard, Pyridium etc.
alteration in urinary habits? sm
Subject: alteration in urinary habits? sm
---From University of Florida ROS page:---
Genitourinary
Urgency, frequency, dysuria, nocturia, hematuria, polyuria, oliguria, unusual (or change in) color of urine, stones, infections, nephritis, hesitancy, change in size of stream, dribbling, acute retention or incontinence, libido, potency, genital stores, discharge, venereal disease
(Female) Age of onset of menses, regularity, last period, dysmenorrhea, menorrhagia, or metrorrhagia, vaginal discharge, post-menopausal bleeding, dyspareunia, number and results of pregnancies (gravida, para)
Urinary tract infection
Subject: Urinary tract infection
urinary tract infection
Subject: urinary tract infection
I know that everyone says "a urinary tract infection," but should it not be "an urinary tract infection?"
Thx - She does have stress urinary incontinence
Subject: Thx - She does have stress urinary incontinence
So I'll bet its that. Going to take another listen.
Thank you so much.
Monteurochannel for urinary incontinence
Subject: Monteurochannel for urinary incontinence
s/l Monteurochannel with ileocystoplasty for urinary incontinence. Cannot find anything even close!
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.
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