Do you write out D&C for surgical history?
Posted By: Kelley on 2009-05-15
In Reply to:
Subject: Do you write out D&C for surgical history?
I know that most of the time we write out acronyms in the surgical history, but for some tests and procedures, the acronym is okay. (Like CT scan, etc)
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surgical history s/l all-tee
Subject: surgical history s/l all-tee
Patient is being seen for balance problems. There is a lot of focus in the report on various tests and her previous tethered cord, lumbar stenosis, laminectomy, etc.
Past surgical history includes: "repair of a spinal fluid leak and (s/l all-tee) then the lumbar spine fusion."
Any ideas as to what the all-tee might be? At first I thought it was the doctor stumbling over her words, but upon re-listening, I'm not so sure!
I do not in surgical history. I only
Subject: I do not in surgical history. I only
expand it if in an op report heading of Procedure Performed:
Surgical History
Subject: Surgical History
"significant for hip replacement, "appy"????
B&B in past surgical history
Subject: B&B in past surgical history
Anyone know what that could be?
Would that be under past surgical history though as he says it is? nm
Subject: Would that be under past surgical history though as he says it is? nm
nm
past surgical history
Subject: past surgical history
She has had repair of cataracts s/l "in aretnas". I couldn't hear retina. Anyone?
Past surgical history is? nm
Subject: Past surgical history is? nm
nm
Past Surgical History
Subject: Past Surgical History
Doc is dictating patient's past surgical history. States she had s/l a budd kay or e malformation based on her MRI at the hospital. Any clues b/c I am at a loss with this one! 
Sounds like past surgical history.
Subject: Sounds like past surgical history.
x
If he's listing past surgical history then
Subject: If he's listing past surgical history then
I'd put appendectomy, three D&C's, tonsillectomy.
D&C stands for dilation and curettage
He only says BTTI under past surgical history and nothing else
Subject: He only says BTTI under past surgical history and nothing else
Is there any past surgical history that might give some clues? nm
Subject: Is there any past surgical history that might give some clues? nm
x
s/l toration of the intestines... past surgical history
Subject: s/l toration of the intestines... past surgical history
Surgical History: s/l harris rods in her spine. SM
Subject: Surgical History: s/l harris rods in her spine. SM
Does not sound like Harrington... sounds just like "Harris rods"
No it was just part of the surgical history, so no content clues available. NM
Subject: No it was just part of the surgical history, so no content clues available. NM
Under surgical history: s/l carpal tunnel ?effers? nm TIA
Subject: Under surgical history: s/l carpal tunnel ?effers? nm TIA
Nothing in the PMH/surgical history or current meds. to give you a clue? nm
Subject: Nothing in the PMH/surgical history or current meds. to give you a clue? nm
s
in past surgical history for a teen *slazon* removal from the eye. ?? TIA! nm
Subject: in past surgical history for a teen *slazon* removal from the eye. ?? TIA! nm
nm
Under past medical history - history of abnormal s/l petatrie functioning. I really cannot make *sm
Subject: Under past medical history - history of abnormal s/l petatrie functioning. I really cannot make *sm
it out. It is a foreigner. He is saying it very fast. History of abnormal petatrie functioning is what is sounds like to me. I have no clue.
history of colorectal history with metastasis to the liver and lymph nodes
Subject: history of colorectal history with metastasis to the liver and lymph nodes
Proctectomy: Surgical resection of the rectum or Prostatectomy: Surgical removal of the prostate gla
Subject: Proctectomy: Surgical resection of the rectum or Prostatectomy: Surgical removal of the prostate gland.
Thank you, I will also write this down.
Subject: Thank you, I will also write this down.
x
How do you write this....
Subject: How do you write this....
When the dictator says, "enclosure and copy cc to"...
Thanks!
how to write this.....
Subject: how to write this.....
one more question for today.........
How do I correctly write the 1-to-100,000 in this sentence?.........
2% Xylocaine with 1-to-100,000 epinephrine was injected subcutaneously
how to write something please....
Subject: how to write something please....
MRA: Abdominal aorta. No evidence for renal artery stenosis. OR
MRA abdominal aorta. No evidence for renal artery stenosis.
The doctor started out with the ECG findings then went to this. Or would this go under the ECG heading? Thanks
How to write it:
Subject: How to write it:
1:1,000 as a ratio
How to write Q.o.d.
Subject: How to write Q.o.d.
q. o.d. or Q.o.d. or qod?
I cannot find that one in BOS.
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How would you write this? sm
Subject: How would you write this? sm
"When he Valsalvas I can appreciate the hernia..." Would it be Valsalva's or valsalvas, or what? TIA
Not sure how to write this
Subject: Not sure how to write this
generally a one-on-one student-faculty rotation. Should I have the hyphens between all of these or just one on one? Not sure which would be correct. This is a letter of recommendation and need to be correct with it.
Thanks
Write it out per BOS II. nm
Subject: Write it out per BOS II. nm
s
Thank you. I will write that one down!! nm
Subject: Thank you. I will write that one down!! nm
Don't know how to write this...
Subject: Don't know how to write this...
Patient has had recent diagnosis of diabetes with recent hemoglobin A1c over 12.
Thanks in advance!
how to write JVP
Subject: how to write JVP
JVP is estimated at 8-10 cm of water at 90 degrees? Is this correct? I have never heard this type of description before.
how would you write this?
Subject: how would you write this?
The final diagnosis was a "grade 2 of 3" mixed glioma
Would you write "2 of 3" or would you write 2/3?
I wasn't sure...thanks!
How do you write....
Subject: How do you write....
an expression of solution such as if dictated like one to one thousand, would I write is like this 1:1000?
how do I write this?
Subject: how do I write this?
How do I write the "eight two fraction" part???
The patient does have a hypochromic microcytic anemia and her hemoglobin electrophoresis does show a reduced hemoglobin A with an increased "8, 2 fraction" and increased hemoglobin F, all compatible with her history of beta thalassemia
How to write this . . . SM
Subject: How to write this . . . SM
Platelets are elevated at "twelve sixty eight"
12.68 ?
PSA - do you write this out?
Subject: PSA - do you write this out?
I am working on a History and Physical Examination, he dictated after the History the following: PSA, on Nilandron 150 mg daily, has been elevated but stable with last PSA 4.8. Do I need tp type it like this? Prostate-specific antigen (PSA), on Nilandron 150 mg daily, has been elevated but stable with last PSA 4.8. Since this is the first mention of the PSA or is that LAB where it should be understood?
how would you write this?
Subject: how would you write this?
She has an approximately [25 pack year history] of smoking...
Would you leave it like that or would you write [25-pack year history] or [25-pack-year history?]
Thanks!!!!
How would you write this...
Subject: How would you write this...
This just isn't sitting right with me, and I think the doctor's old service (his nurse) has been doing this wrong for awhile now. I just took over this account and have been reviewing and comparing old notes with current dictation.
"The patient was injected with "a quarter percent" Marcaine and morphine."
She was typing this as 25% - It should be 0.25% shouldn't it. I'm so tired right now I need to go to sleep, but have to turn this job in first. Thanks for helping. ME
Thanks so much! Will write it in my book. nm
x
how to write "..well-corticated..."
Subject: how to write "..well-corticated..."
Just a general question: It seems a significant percentage of radiologists will use the term "well corticated" to describe an accessory ossicle or perhaps old trauma to differentiate what may appear to be an acute fracture. Since "corticated" is not an actual word, can anyone help with an appropriate way to rephrase this? eg "At the distal tip of the fibula is a well-corticated bony lesion, likely an accessory ossicle or old trauma and not an acute fracture."
maybe "lesion with good cortical margins" or some such, but wondering if there are other suggestions.
Thanks.
yes, unless you want to write herniae instead.
Subject: yes, unless you want to write herniae instead.
x.
I would write it out even if it is verbatim
Subject: I would write it out even if it is verbatim
PPD is a test for tuberculosis. You aren't just writing a document to appease the doctor. You are writing a legal document that many other people may want to read, including an insurance auditor or a lawyer, neither of which may have any clue what PPD means EVEN IN THE CONTEXT OF THE SENTENCE and will have no inclination to look it up.
That's just me, someone who audits physician records and slaps them on the wrists for this like this, but you do want you want.
i always write the word out nm
Subject: i always write the word out nm
x
I write it as such, 3490
Subject: I write it as such, 3490
is the doc saying 3,490? I have been told no commas.
cardiology how to write something
Subject: cardiology how to write something
LVH with TRS widening and repolarization abnormality.
TRS is it TRS or TRs
Thank you
Deborah
Proper way to write T. Max? nm
Subject: Proper way to write T. Max? nm
TIA
how to write P0313
Subject: how to write P0313
He says she is a G4 P0313. Is this correct?
Thank you
Deborah
I don't think so. You never write 8:00 o'clock. nm
Subject: I don't think so. You never write 8:00 o'clock. nm
f
Just wondering how some of you would write this.
Subject: Just wondering how some of you would write this.
He put his arm through a window and had
40 some odd stitches.
Is it just as I put it above or are there hyphens? Never run into this.
Thanks!
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