Depends on what your QA says, but I separate out the entities and only use headings if
Posted By: they give them. nm on 2007-05-17
In Reply to: Headings - Jennie
Subject: Depends on what your QA says, but I separate out the entities and only use headings if
s
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- Headings - Jennie
- Depends on what your QA says, but I separate out the entities and only use headings if - they give them. nm
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Just means 2 separate entities. It would fit. Or maybe it's "continued?" nm
Subject: Just means 2 separate entities. It would fit. Or maybe it's "continued?" nm
s
It's really up to your client. The trend is to not capitalize depts. or entities
Subject: It's really up to your client. The trend is to not capitalize depts. or entities
s
Headings
Newbie here. If a doc dictates a laboratory data and lists lab values, then talks about x-rays and ekgs, do you include that in the lab section or make a separate heading for x-rays and ekgs (what would you title that section?). Thanks for any info.
Headings
Subject: Headings
I am transcribing a History & Physical Examination Report (Neurology)
The headings confuse me terribly. What would the heading be for the following:
Orientation and language are normal fundi with sharp disks bilaterally.
I have the following:
NEUROLOGIC: Patient walks to the right occasionally. She has trouble getting started because of discomfort. She can walk on heels and toes briefly. However, on tandem walk she really has difficulty with that. She does not line up her toes easily and loses her balance very easily with that. (Is that the correct heading?)
Also, does anyone have a good website for determining headings?
headings
Subject: headings
Thanks so much. Does it get better?
Headings
Subject: Headings
If in a report , broke into 2 sections.. MRI of the Right leg then left..
and said
History
Technique
then
Technique
History
would it be a good idea to switch order for consistancy?
not an answer on headings, but
Subject: not an answer on headings, but
Sorry, I don't have a quick answer about your headings, but I wanted to let you know that your first sentence should be 2 sentences: Orientation and language are normal. Fundi with sharp disks bilaterally. (Fundi and disks/discs refer to the eyes, nothing to do with orientation or language.) Good luck with the headings - I still get confused sometimes on them too if I don't have a specific format to follow.
If QA has no recommendations, you don't have to have headings in there at all. Just do the report
Subject: If QA has no recommendations, you don't have to have headings in there at all. Just do the report
s
verbatim, abreviations, and headings?
Subject: verbatim, abreviations, and headings?
typing verbatim. In headings PREOPERATIVE DIAGNOSIS and POSTOPERATIVE DIAGNOSIS, when doc says same for POSTOP. Do you type same when typing verbatim?
Progress Note headings?
Subject: Progress Note headings?
I really want to hear Chief Complaint, but I’m sure he starts with Cardio. Thanks anyway.
Progress Note headings?
Subject: Progress Note headings?
I can’t hear the “tat” part, but that sure makes sense. I like the cardiovascular, too, except this is talking about GERD - could that be connected to Cardiovascular system?
Headings are allowed to be added.
Subject: Headings are allowed to be added.
It would look weird without a heading. Thanks.
History & Physical Headings
Subject: History & Physical Headings
I am trying to head a H & P what do I list the bladder and groin under?
History & Physical Headings+1>?
Subject: History & Physical Headings+1>?
Thanks. One more question. What headings do you add if not transcribed to the H & P?
Would depend on your account and whether they allow headings where necessary or not. If heading is w
Subject: Would depend on your account and whether they allow headings where necessary or not. If heading is warranted, I would use CLOSURE.
Interstital tissue and pelves need headings?
Subject: Interstital tissue and pelves need headings?
Spleen: The spleen has a thin fibrous capsule. Malpighian bodies are indistinct the sinusoids are moderately widened.
Liver: Sections of the liver show a thin fibrous capsule. Multiple small fatty vacuoles are noted in the cytoplasm. Portal spaces are fairly small in size. There is mild widening of the sinusoids in the central zones.
Kidneys: The kidneys have a thin capsule. The cortices that show glomeruli of normal appearance. The tubules are not remarkable.
Interstitial tissue showed no note worthy change. The pelves are not remarkable.
In this instance.. does the interstitial tissue and pelves need their own headings.. or is this correct?? Thanks
They are separate. sm
Subject: They are separate. sm
The common bile duct is the duct formed by the union of the cystic duct (from the gallbladder) and the hepatic duct, which is formed by the intrahepatic biliary tree.
Separate them. nm
Subject: Separate them. nm
s
It should be separate, SAD/DCR or SAD-DCR, or SAD, DCR
Subject: It should be separate, SAD/DCR or SAD-DCR, or SAD, DCR
Shoulder arthroscopic debridement and distal clavicle resection. Gotta love these docs and their neverending shortcuts, just lazy behinds. LOL
No they do not go together. Separate
Subject: No they do not go together. Separate
x
I personally would just separate
Subject: I personally would just separate
by a slash 500/500/250/500, but that's just me :)
Could he mean separate consult?
Subject: Could he mean separate consult?
Ugh..can you separate your s/l into syllables for us, please? Thx. nm
Subject: Ugh..can you separate your s/l into syllables for us, please? Thx. nm
s
Well, BOS pg 12 says use a comma to separate 2 or
Subject: Well, BOS pg 12 says use a comma to separate 2 or
v
Can you separate your s/l into syllables for us? nm
Subject: Can you separate your s/l into syllables for us? nm
s
Yes, 2 separate items. nm
Subject: Yes, 2 separate items. nm
s
No they are three separate views.
Subject: No they are three separate views.
No they are 3 separate views.
It is the sentence structure that is confusing. Three individual views, but once the word views gets put into the sentence it becomes plural and without the word views it is regarded as singular. I don't necessarily agree, but I believe this is why the QA department and your manager keep changing your grammar.
I believe tumor is separate...
Subject: I believe tumor is separate...
"s/l H nerve, tumor, or other..."
I keep them separate, i.e. mid portion.
Subject: I keep them separate, i.e. mid portion.
x
Seems like that goes with Nystatin and not a separate drug -
Subject: Seems like that goes with Nystatin and not a separate drug -
x
it is prothrombin time, to separate....sm
Subject: it is prothrombin time, to separate....sm
When it is really prothrombin time, it makes NO sense to type pro time as 2 words....I really don't care what BOS says about this one particular issue. The word really is prothrombin time and MDs say protime....I give them protime. Just my take on it.
Sorry. Put answer on separate entry. nm
Subject: Sorry. Put answer on separate entry. nm
Could your s/l be something separate from "cardiac disease," sm
Subject: Could your s/l be something separate from "cardiac disease," sm
such as whatever it is, cardiac disease, and congestive heart failure. Any clues in the rest of report?
This has got me stumped.
I believe the are 2 separate diagnoses and would transcribe as such.
Subject: I believe the are 2 separate diagnoses and would transcribe as such.
.
Are you hearing this with an accent? Can you separate it into
Subject: Are you hearing this with an accent? Can you separate it into
s
Also, with the periods it would be 3 separate words, which it is not...
Subject: Also, with the periods it would be 3 separate words, which it is not...
cerebrovascular accident always has been CVA (hard to keep up with so many new rules).
can only find two separate angles. sm
Subject: can only find two separate angles. sm
metatarsus adductus angle, and intermetatarsal angle. You probably already knew that, and it probably doesn't help decipher what your doc really means.
2 separate vital signs nm
Subject: 2 separate vital signs nm
nm
I agree, 3 separate things. nm
Subject: I agree, 3 separate things. nm
.
If not dictated separate, then combine.
Subject: If not dictated separate, then combine.
x
maybe "sent separately" - as in a separate specimen
Subject: maybe "sent separately" - as in a separate specimen
The doc says, through a separate subfascial skin incision when...sm
Subject: The doc says, through a separate subfascial skin incision when...sm
harvesting iliac crest during a spinal fusion. It doesn't make sense to me. I would think it would need to be either a separate subfascial incision or a separate skin incision. I have never heard it described this way before and I don't think it makes sense his way.
I have always used and seen S1, S2, two separate heart sounds during auscultation......nm
Subject: I have always used and seen S1, S2, two separate heart sounds during auscultation......nm
nm
I have always used and seen S1, S2, two separate heart sounds during auscultation......nm
Subject: I have always used and seen S1, S2, two separate heart sounds during auscultation......nm
nm
antinuclear antibody is separate test from CBC...sm
Subject: antinuclear antibody is separate test from CBC...sm
may be saying antinuclear antibody assay and CBC?
Pretty sure they're two separate problems. nm
Subject: Pretty sure they're two separate problems. nm
Thanks so much! I knew of the two separate, but questioning myself on something I didn't know.
Subject: Thanks so much! I knew of the two separate, but questioning myself on something I didn't know. Thx
They're all likely related, but I'd personally do 3 separate dxs. n/m
Subject: They're all likely related, but I'd personally do 3 separate dxs. n/m
In the sentence you describe, I would not separate by common and use v or vs instead, as cited by...
Subject: In the sentence you describe, I would not separate by common and use v or vs instead, as cited by...
Cambridge Dictionary:
(WRITTEN ABBREVIATION v or vs) used to compare two things or ideas, especially when you have to choose between them:
i.e., private education versus state education
Yes, but if lab stuff, try and separate the "components" if you're sure of them with semico
Subject: Yes, but if lab stuff, try and separate the "components" if you're sure of them with semicolons or
s
This is grip strength bilaterally. The others were on separate hands.
Subject: This is grip strength bilaterally. The others were on separate hands.
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