Format for multiple problems

• Format for multiple problems - tf
  • Here's what I mean - tf
    • Here's what I'd do. sm - nm
    • Since no QA, just do what you feel - FT MT
    • If QA has no recommendations, you don't have to have headings in there at all. Just do the report - as separate paragraphs for each prob. nm
  • Best to ask your QA how the client prefers this to be done. nm - nm
  • Can you see samples of how the other MTs handle it? Are these SOAP notes? Can you number the probs - under Assessment/Plan? nm
  • Not sure what you mean. - FT MT

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5/5 strength throughout sensation is intact.  So the 5/5 is not at the start of the sentence, how would you reword this phrase?

Would it be MEDICATIONS: Include

1.

2.

3.

Just when I think I have it on format - I don't.  The following is under PHYSICAL EXAMINATION.  What would the subheading be?

Hi... Can someone tell me the correct format for what comes after this med in a dictation:  "Zarontin 250 mg 500 500 250 500?"  Is this 500 am, 500 mid-am, 250 afternoon, 500 bedtime?

Thanks! 

Hi, I'm wondering whether AAMT BOS says to type this:  "image #31 series 3" or this: "image #31, series 3."  Comma or no?

Thank you!  :D

This is so small I hate to ask, but everytime I type this it just looks odd no matter what way I type it and would like to know how another MT would type this. 

If someone has a dull aching sensation or sharp stabbing sensation would you hiphenate (dull-aching sensation) or slash (dull/aching sensation) or just leave it (dull aching sensation)?  Thanks for any input to my "stupid" question.  

I was hoping someone might be able to give me the rule for this.....Should departments be capitalized?  For instance, "she saw University of Virginia orthopedics"  Should orthopedics be capitalized or not? I'm always confused about this:)

Okay, I am an old gal working mostly ias in-hospital MT (VA, Teaching hospital), but I did also work off and on for MTSOs at home.   Now going back a long time, I was always taught that in formatting Problem Lists or Hospital Course by problem list you transcribe it this way.   Problem #1 - HYPERTENSION.  The patient is taking lisinopril currently.....  or if the doc did not say PROBLEM #1, then you transcribed it 1.  HYPERTENSION.  Blah, blah, blah.   When did this change and become wrong?  Most of the docs I am now transcribing for one of the major MTSOs now (left the hospital), actually ask that we capitalize the major problem.  Is this in the so-called AHDI BOS2? 

IMHO, using the capitalization on the problem is much easier to read, than this...

1.  Hypertension.  The blah, blah, blah..

2.  Diabetes mellitus type 2.  Uncontrolled.  Not compliant.

Any QAers out there can answer this one for this old school nitpicker?

Capitalize verbal, performance, and full-scale?  Should I leave the subtest scores in a vertical list arrangement or use a different format?

On this administration of the Wechsler Adult Intelligence Scale-III, Mr. ___ obtained a verbal IQ of 57 (range 53-63), a performance IQ of 64 (range 59-73), and a full-scale IQ of 56 (range 53-61). These scores fall within the mild range of mental deficiency.

The following scatter of subtest scores was obtained:
VERBAL:
Vocabulary: 2
Similarity: 3
Arithmetic: 2
Digit Span: 3
Information: 3
Comprehension: 2

PERFORMANCE:
Picture Completion: 4
Digit Symbol: 4
Block Design: 4
Matrix Reasoning: 5
Picture Arrangement: 4

All the scores above fall within the mentally deficient range and are relatively even.

DIAGNOSTIC ASSESSMENT:
AXIS I: Psychosis NOS, schizoaffective disorder, bipolar type versus bipolar I disorder versus a drug induced psychosis, also polysubstance abuse.     Should the word versus be transcribed as a slash or another format in this example?  Thanks!

I never usually have to type letters so I am unsure of the format.  Are we supposed to type the "Sincerely," and are we supposed to indent it? 

Thanks!

I go like so

Axis   I

          xxxxx

          xxxxx

          xxxxx

Axis   II

Axis  III

Axis   IV

Axis   V

and occasionally used today but rare.....

Is there such a thing as a multiple vitamin D?  I'm not sure if he is saying just multiple vitamin, which would make sense...but then it sounds like he sticks in the word "D"  Has anyone ever had that dictated?

Thanks.....

intraluminal air within the gastrointestinal tract that has the appearance of an ileus.

Flexions???? Anyone?

Thanx

high prematurity rates and (sounds like "manano" compromise of the fetus. 

thank you for your help :)