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Doctor dictates Actos plus met 15/850 mg daily. nm

Posted By: Would you type metformin, or leave it? on 2008-01-08
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nm

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Doctor dictates Actos plus met 15/850 mg daily. nm - Would you type metformin, or leave it?
- Brand name is ACTOplus met - so guess should leave as dictated? - ltt

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The doctor dictates
Subject: The doctor dictates

His aortic valve appeared well-(s/l seated). I found some examples like that, but am unsure of certainty and spelling accuracy? Thank you in advance for any help.

Doctor dictates ALT 1413 and AST 681? Should it be 14.31 and 6.81? TIA!
Subject: Doctor dictates ALT 1413 and AST 681? Should it be 14.31 and 6.81? TIA!

doctor dictates and spells cellulagia
Subject: doctor dictates and spells cellulagia

I cannot find or verify this anywhere. Is this even a word?

Type it exactly as the doctor dictates, verbatim....nm
Subject: Type it exactly as the doctor dictates, verbatim....nm

nm

Formatting when doctor dictates "question..."
Subject: Formatting when doctor dictates "question..."

Dictated: "Patient was prescribed question Pyridium"

How would I transcribe this? Would I type, "Patient was prescribed Pyridium?"

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Trileptal 150 b.i.d.; s/l "Vantz" as tolerated; Cymbalta 30 mg daily; verapamil 24 mg daily.
Subject: Trileptal 150 b.i.d.; s/l "Vantz" as tolerated; Cymbalta 30 mg daily; verapamil 24 mg daily.

Pt with chronic headache, chronic back pain, factor V Leiden.

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s/l luvensa 4 capsules daily and s/l Exforge 10/160 mg one daily
Subject: s/l luvensa 4 capsules daily and s/l Exforge 10/160 mg one daily

Actos? nm
Subject: Actos? nm

!

Actos is for diabetes
Subject: Actos is for diabetes

Actos? (for diabetes)
Subject: Actos? (for diabetes)

Actos -- Apidra --Actoplus Met --? any of these? nm
Subject: Actos -- Apidra --Actoplus Met --? any of these? nm

Actos for swelling of feet?
Subject: Actos for swelling of feet?

Decrease Metformin to once a day. Will probably reduce Actos to 30 mg a day to decrease the swelling of his feet.

It sounded right but is Actos going to help swelling of the feet? He said throughout the report he had swelling of the tongue. He has type 2 diabetes and sugar levels are running low. Just checking another opinion.

The patient cannot take Actos or s/l TCVs because of fluid retention.
Subject: The patient cannot take Actos or s/l TCVs because of fluid retention.

:-)

daily versus q. daily?
I always thought q. daily was wrong, but have received back corrections from QA with q. daily after I had changed it to daily. This is not a verbatim account. Am I wrong?

q.daily versus daily
Subject: q.daily versus daily

You are definitely right. Q.daily and q.day, q.d. are not accepted by the AAMT Book of Style. You are to put daily.

A side effect of Actos is swelling - prolly why dosage is being reduced - nm
Subject: A side effect of Actos is swelling - prolly why dosage is being reduced - nm

Under PMH. MD dictates: sm
Subject: Under PMH. MD dictates: sm

Status post trauma/repair to patient�s eye.

Would you leave this as is with the slash or change it? I am permitted to change things when necessary. Thanks.

What do you do when the doc dictates sm
Subject: What do you do when the doc dictates sm

... and I gave the patient 50 "mikes" of whatever medication. One said to spell it m-i-q-u-e-s, one said to use m-i-k-e-s, and one hospital said not to use it at all. So, does it stand for micrograms? Should we use slang? Aghh! Help, please.

I would put as doc dictates..sm
Subject: I would put as doc dictates..sm

if he says "calcium one every day" I would not input the q.d., but I would expand it as "calcium, one tablet every day." jmo and how I have been doing it with no complaints.

Exactly the way MD dictates it
Subject: Exactly the way MD dictates it

If the patient could see anything at all (I had one today where the patient could see 20/1760), then the MD would have given the value, but when there is nothing there, you just type nothing. I have a verbatim account, but even if I didn't, I still would not change it to 20/0 as that lone "0" could be mistaken as something else.

If a Dr. dictates
Subject: If a Dr. dictates

"posterior tib", meaning posterior tibial artery, do you type the abbreviation or go ahead and type out tibial?

if that's the way he/she dictates it...then yes I would. nm
Subject: if that's the way he/she dictates it...then yes I would. nm

xxx

Think that one is bad? my md dictates things like this...sm
Subject: Think that one is bad? my md dictates things like this...sm

I used a small, tiny, little Q-tip .... and he doesn't want me to change it. Bizarre!!!

I have a doc that dictates same thing
Subject: I have a doc that dictates same thing

mine means adenosine thallium

I leave it as whatever the doc dictates.
Subject: I leave it as whatever the doc dictates.

It's not my job to keep them politically correct.

Do I change it when he dictates cc? nm
Subject: Do I change it when he dictates cc? nm

!

I have a psychiatrist who dictates like that. sm
Subject: I have a psychiatrist who dictates like that. sm

I leave most of his stuff as is even though the account is not verbatim. A lot of times I end up wondering WTH he is talking about. When I first got his dictations I was going back to read and relisten because I thought I must have scrambled something. Give them what they dictate, if they don't like what they read maybe they'll take the time to think before they dictate next time.

when doc dictates L-thyroid sm
Subject: when doc dictates L-thyroid sm

Does he mean levothyroxine or Levothroid?

Dictates died s/l **min** CVA
Subject: Dictates died s/l **min** CVA

Dictates died from m-i-n CVA. I can't verify min CVA anywhere. Any suggestions?

dictates **phagiagram**
Subject: dictates **phagiagram**

He clearly dictates *phagiagram* or something that is VERY similar to that. I don't hear a *dys*. I tried google and am getting zero hits.

Do you think I should I QA it or would it be fine to just use *phagiagram*?

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You transcribe what he/she dictates.
Subject: You transcribe what he/she dictates.

You transcribe the values as dictated. If he says "Cholesterol profile" and then just lists the values, then I would put a colon after profile and just list them.

I have an ESL who dictates a lipid profile
Subject: I have an ESL who dictates a lipid profile

and then says "lipid profile comment NIHN." What in the world does that mean?

whatever doc dictates. Would not use beats/minute tho. nm
Subject: whatever doc dictates. Would not use beats/minute tho. nm

Yes. I transcribe for a cardiologist who always dictates
Subject: Yes. I transcribe for a cardiologist who always dictates

Could be, although he only dictates 1 syllable. I think I will flag. Thanks.
Subject: Could be, although he only dictates 1 syllable. I think I will flag. Thanks.

provider dictates bivicd sm
Subject: provider dictates bivicd sm

Would you put bi-V ICD, biV-ICD, bi-V-ICD or something else? Says it multiple times in note. Thanks!

dictates ureteral meatus
Subject: dictates ureteral meatus

Could that be right? Or do you think dictator means urethral? Talking about vesicoureteral reflux in a male.

Thanks!!!

Is it Mersa or MRSA? he dictates
Subject: Is it Mersa or MRSA? he dictates

Doc dictates 3/5 systolic murmur (sm)
Subject: Doc dictates 3/5 systolic murmur (sm)

I always thought the last number was 6. Does this make sense? TIA!

The patient has MS, dictates she cannot s/l antigravitate the leg.
Subject: The patient has MS, dictates she cannot s/l antigravitate the leg.

Have not heard the term antigraviate before, and cannot find it anywhere. That is all the context I have

grr. doc dictates s/l alipta, spells a-l-m-i-t-a. sm
Subject: grr. doc dictates s/l alipta, spells a-l-m-i-t-a. sm

It's a second choice chemotherapy agent after carboplatin/Taxotere rejected by patient. Any thoughts?

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dictates what sounds like omPUREizole
Subject: dictates what sounds like omPUREizole

I'm not finding this anywhere. Anyone have a clue?

dictates glucocheck/glucochecked
Subject: dictates glucocheck/glucochecked

Is that right? I can't 100% verify.

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Your choice unless client dictates different.
Subject: Your choice unless client dictates different.

Okay, I'm not explaining right. Doc actually dictates "Positive Hepatitis CAB". nm
Subject: Okay, I'm not explaining right. Doc actually dictates "Positive Hepatitis CAB". nm

In Vital SIgns, doc dictates "MAP 77". ?? sm
Subject: In Vital SIgns, doc dictates "MAP 77". ?? sm

VITAL SIGNS: Temperature 36.0, pulse rate 62, respiratory rate 16, systolic 112, diastolic 160, MAP 77.

I work for a general surgeon who dictates...sm
Subject: I work for a general surgeon who dictates...sm

sestamibi scan on all his parathyroid patients...........

and google to back it up:

He dictates in SOAP format so that might look out of place.
Subject: He dictates in SOAP format so that might look out of place.

Dictates doesn't have a *dysconjative* gaze
Subject: Dictates doesn't have a *dysconjative* gaze

Thanks!

he is dictating is backwards. I would type it as he dictates...nm
Subject: he is dictating is backwards. I would type it as he dictates...nm

xx

Doctor dictates Actos plus met 15/850 mg daily. nm

Sestamibi Scan for Parathyroid Disease. Sestambi parathyroid x-ray ...

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Sestamibi scanning for Parathyroid tumors and adenomas.

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