Don't be confused by dift opinions. Blank if unsure. However, docs dictate one-teens all the ti
Posted By: Get feedback from your QA- on 2008-03-05
In Reply to: Doc dictates that blood sugars are in the one-teens SM - tiff
Subject: Don't be confused by dift opinions. Blank if unsure. However, docs dictate one-teens all the time.
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my docs say 90 to 1-teens all the time
Subject: my docs say 90 to 1-teens all the time
nm
I would say 1-teens also. Some docs phrase it this way a lot. Hope this helps.
Subject: I would say 1-teens also. Some docs phrase it this way a lot. Hope this helps.
nm
welcome; got it from my docs that dictate it as i never could figure them all out either, lol. nm
;
LOL..the way these docs dictate anymore
Subject: LOL..the way these docs dictate anymore
who knows!! Something like that just check your aspirin bottle. Good luck!!
Derm docs often dictate "Allergy to CARBO mix" - sm
Subject: Derm docs often dictate "Allergy to CARBO mix" - sm
I don't know what the full word is, but this validates your hearing the partial "carbo"
there is the abbreviation MAR docs dictate for medication administration record, but not sure...sm
Subject: there is the abbreviation MAR docs dictate for medication administration record, but not sure...sm
if that's it? This is usually dictated when they don't want to list the entire medication list so refer to the MAR that is in the chart.
If unsure blank it and don't waste your
Subject: If unsure blank it and don't waste your
x
Then leave it blank if you are unsure.
Subject: Then leave it blank if you are unsure.
x
opinions please (sm)
Subject: opinions please (sm)
Wondering what most people type for dosing units in the millions:
3 million units or 3,000,000 units
From what I see in BOS II, it can be typed either way. I just typed 3,000,000 units thinking it may be a little more clear on a medication list, but now I am second-guessing, so I am looking for opinions on this. Thanks 
I have 2 opinions on this --
Subject: I have 2 opinions on this --
1) Miralax is generally given 17 g - half would 8.5 g. That one grabs me more than the abbreviation issue.
2) g is an acceptable abbreviation for grams, but a lot of clients prefer it written out when used alone - much like the word liter when used alone. It can sometimes be difficult to discern in the report. If your client has no preference, I would continue to use g and just chalk it up to the QA's preference.
Opinions are what the board is here for..
Subject: Opinions are what the board is here for..
nm
opinions - how do you all type
Subject: opinions - how do you all type
this - the dictator says the nodule was FNA'd or I&D'd, etc. It just seems awkward.
Need opinions or facts
Subject: Need opinions or facts
Most docs dictate possesion for Hodgkin's lymphoma, Meckel's cavity, Gerota's fascia, Morison's pouch, etc. You get the picture. All of my references have these without possession. What is the standard for transcribing? I was told at one point to leave off the 's and type as referenced. Do you agree?
Think I figured it out, but would like opinions.
Subject: Think I figured it out, but would like opinions.
I've never heard this, but I've only recently started typing GYN reports.
Patient has bacterial vaginosis. Doc is saying --- MetroGel 0.75% one application s/l p.v. q.h.s. x5 nights.
Stedman's abbv lists p.v. as by way of vagina, so that makes sense? Would just like to know if anyone has heard this. Thanks.
I need opinions on formatting. SM
Subject: I need opinions on formatting. SM
The patient was seen by Dr. John Smith of the cardiology service.
OR
The patient was seen by Dr. John Smith of the Cardiology Service.
This always messes me up! I've done it the second way for many moons, but I'm training a new girl who says according to the BOS, I'm wrong. Just wondering how everyone else does it.
Opinions please - This doesn't seem right...
Subject: Opinions please - This doesn't seem right...
Patient prescribed prednisone 5-mg, 6-day taper. Doesn't that seem like a low dose of prednisone to do a taper?
I'm sure there will be differing opinions..
Subject: I'm sure there will be differing opinions..
but I'm going to go out on a limb and say PL simply means posterolateral.
one-teens is how I'd do it....nm
Subject: one-teens is how I'd do it....nm
1-teens
Subject: 1-teens
nm
1-teens (113 thru 119)
Subject: 1-teens (113 thru 119)
nm
Getting this a lot lately, I put 1-teens!
Subject: Getting this a lot lately, I put 1-teens!
nm
Opinions needed on my tweaking ... sm
Subject: Opinions needed on my tweaking ... sm
Here's my tweaking: I think it looks okay except for the last sentence. Can anyone help me make that last sentence look better? Thank you.
Dear xxxx :
I am pleased to write a letter of recommendation for XXX who is applying to your program. XXX spent a week with me in my internal medicine office this past summer. He is currently a student at XXX and has decided on a career in a medicine. In the process of starting his medical career, xxx has spent time with multiple physicians to show that he is serious about a career in medicine. He has excellent personal skills, as you will see when you interview him.
During the time I spent with xxx he asked intelligent questions and showed a genuine interest. His thought process seemed both logical and rational during our discussions.
Based on my experiences with x, I recommend highly that he be accepted in your training to become an xxx physician. I believe he has all the makings of good physician, intelligence hard-working, motivated, and personal.
Opinions needed See MSSG
Subject: Opinions needed See MSSG
Question: would you put "Romberg negative. No pronator drift. Gait is normal." under extremities or neuro? Thanks
EXTREMITIES: No clubbing, cyanosis, or edema. Distal pulses are 2+ and equal throughout. Romberg negative. No pronator drift. Gait is normal.
NEUROLOGIC: Cranial nerves II-XII are intact. DTRs are 2+ and equal throughout. Romberg negative. No pronator drift. Gait is normal.
Thanks a million. Opinions at this point even help!
Subject: Thanks a million. Opinions at this point even help!
need opinions on the correct way to type this
Subject: need opinions on the correct way to type this
The patient has no discharge drainage or pus.
Initially I thought "drainage, discharge" with the comma but does it make sense without the comma? 
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?
for one-teens, I would type 110's (s/m)
Subject: for one-teens, I would type 110's (s/m)
since he goes on to say 120's (which are the numbers 20-29) so 110's (would be all the "teens..." would be 10-19. Hope that helps!!
if says 1-teens then yours is fine
Subject: if says 1-teens then yours is fine
nm
"one-teens" is the way I would put it.
Subject: "one-teens" is the way I would put it.
It is exactly what he said, but not the usual way of expressing it, thus the " ".
100s to 1-teens
Subject: 100s to 1-teens
nm
Teens or 10s? Please see message.
Subject: Teens or 10s? Please see message.
The doctor dictates: The plan is if his platelet count drops to the teens, to transfuse him. My questionn is - it is okay to type "teens?" Or, should it be "10s?" TIA
Type as teens
Subject: Type as teens
More opinions needed. 2 people are disagreeing here. TY
Subject: More opinions needed. 2 people are disagreeing here. TY
I type one-teens because that's how I was told to do it. nm
Subject: I type one-teens because that's how I was told to do it. nm
"peak pressure" in the teens
Subject: "peak pressure" in the teens
One-teens is how I type it. Was on QA at the time and was
Subject: One-teens is how I type it. Was on QA at the time and was
one-teen or one-teens is correct. nm.
Subject: one-teen or one-teens is correct. nm.
x
Doc dictates that blood sugars are in the one-teens SM
Subject: Doc dictates that blood sugars are in the one-teens SM
How would you type it? TIA
You should dictate what the doc says.
Subject: You should dictate what the doc says.
If he is wrong, that's his problem. You can't just go changing what he says unless you have free reign on your account.
Drs get what they dictate - some of us only do..S/M
Subject: Drs get what they dictate - some of us only do..S/M
brachioplexus, brachioplexopathy - what they say is what they get....client profile RULES!
How does he dictate it? Is he actually - sm
Subject: How does he dictate it? Is he actually - sm
Is he saying "CBC, MSP, and stool" because stool is not a test so just wondering if it could be the name of a stool test. If you state just how the whole sentence is dictated, it may help us figure it out for ya.
I had a doc used to dictate that
Subject: I had a doc used to dictate that
Good says it stands for keep-open-vein. So, it should fit, and it also is all CAPs. 
Usually if they dictate Seldinger...
Subject: Usually if they dictate Seldinger...
they will say "via Seldinger, or Seldinger technique." I don't believe they would do this en route either. Are you sure you are hearing "sandwich?" I have been transcribing ER reports for years and I have never heard this term used. Anyway, I would not guess on this one. IMO, it is better to leave it blank and have QA inform you later so you can keep it on file .
Yes, that was how I was taught and most always they dictate cc nm
Subject: Yes, that was how I was taught and most always they dictate cc nm
nm
Still unsure. Sent to QA:)
Subject: Still unsure. Sent to QA:)
I tried to fit something like vesicles or bubbles in, but it just didn't match what he said...oh well.
Unsure
Subject: Unsure
Patient is an 18-year-old gravida 1, para 0 who comes in for her first prenatal appointment.
ASSESSMENT: This is about a 27-week pregnancy with uncertain dating in a _____ (s/l pri nep or pri mep??) with late prenatal care.
Unsure
Subject: Unsure
The fact that he has both retinopathy and nephropathy does bouge ill if he continues to have uncontrolled blood sugar readings.
ESL doctor, not sure what he's saying. s/l bouge ill but that really doesn't make sense to me...lol
Unsure
Subject: Unsure
LOWER EXTREMITIES: No edema. No breakdown. The right foot shows an irregularly cut great toenail, but no evidence of infection or tenderness. He continues to have dependent _______________ , more noticeable on the right foot. Pulse is minimal, 0 to 1+.
Blank s/l roo-war
The patient is a diabetic.
Im just unsure. SBN, SDN ? nm
Subject: Im just unsure. SBN, SDN ? nm
?
Unsure of something
Subject: Unsure of something
An ABI was attempted but no pulse could be found around his “ankle.”
ABI means ankle-brachial index? Another way of checking pulse? Just need to understand what is being talked about. Unsure
Unsure
Subject: Unsure
Would it be possible to address with name, title?
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