Headings are allowed to be added.
Posted By: See message on 2007-11-28
In Reply to: What heading would you use? - See message
Subject: Headings are allowed to be added.
It would look weird without a heading. Thanks.
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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?
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?
Depends on what your QA says, but I separate out the entities and only use headings if
Subject: Depends on what your QA says, but I separate out the entities and only use headings if
s
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
added?
Subject: added?
should have added...sm
Subject: should have added...sm
parent/child relational problems is a V code, as it does not pertain to any psychological disorder, whereas Posttraumatic Stress Disoder is not a V code because it is considered a mental disorder.
I should have added...
Subject: I should have added...
This lady had this diagnosis for five months before she died. Thanks again.
Thanks I added that site to my fav. nm
Subject: Thanks I added that site to my fav. nm
x
Thanks -I added that to my "favorites" sm
Subject: Thanks -I added that to my "favorites" sm
It was a stat report so I sent it flagged - didnt see anything resembling "queery" LOL
thank you...added it to my book.
Subject: thank you...added it to my book.
d
oops...added an 'n'
Subject: oops...added an 'n'
sorry should have added sentence..sm
Subject: sorry should have added sentence..sm
There is some hyperlucency noted on the ____ s/l "tricotrim" of the wrist although awaiting radiology report.
I didn't think they allowed it on
Subject: I didn't think they allowed it on
nm
How many times allowed help?
Subject: How many times allowed help?
She has a combination of s/l kramedonol acne and acne rosacea.
Thanks- I will make this one my last for tonight! - Thanks
Is q.a.c. allowed in any form?
Subject: Is q.a.c. allowed in any form?
thx
nope - not allowed....
Subject: nope - not allowed....
True, it is in all what you are allowed or not
Subject: True, it is in all what you are allowed or not
allowed to do. However, at one of the first hospitals I worked for (back in the early 80s) for example, we had a doctor who was constantly using abbreviations which we were not allowed to do in diagnosis. I will NEVER forget this. His diagnosis was "P.M.S.O.B." The transcriptionist, of course, changed this in the diagnosis to read "Shortness of breath at night." He flew off the handle - this abbreviation meant "poor, miserable, son of a B****" and that is what he wanted in the chart. It was referred to the Hospital Director who told our department manager that even though this was definitely not correct, he dictated it and wanted it there and there was not much we could do about it if we wanted to keep our jobs. This is a lesson that taught me never to second guess a physician. Granted this was not at all politically correct (we didn't have that term back then), but that is what he wanted, so I don't change anything in that vein - I may question it and flag it for the higher ups, but I don't change it.
Should have added patient's other medications
Subject: Should have added patient's other medications
She's on levothyroxine for her thyroid, Lipitor for her cholesterol, verapamil for her hypertension so I'm really confused here.
Thanks again! :-)
so only Americans are allowed to post on here? nm
Subject: so only Americans are allowed to post on here? nm
:(
I am allowed to edit and correct
Subject: I am allowed to edit and correct
I am allowed to make changes to what he says, which is why I asked the question. I am allowed to edit and change what the doctor says and how he says it - and I do a lot of that in the course of the day because some of the things he says are just a mess. "Retarded" did seem a little derogatory to me and I think I will put it in better terms than that.
I guess it comes down to what the rules are that you work by - whether you can edit or if you are verbatim. If it was verbatim I wouldn't have questioned it (even thought I personally feel it is insulting) but since I have the option to change it, I was just wondering what the correct term was now because I know it keeps changing. Thanks for all the opinions!
Test questions are not allowed here.
Subject: Test questions are not allowed here.
If I remember correctly, test questions are not allowed on this board. You must pass the test on your own merits.
If not verbatim account and you are allowed
Subject: If not verbatim account and you are allowed
to add headings, I would put it under either MUSCULOSKELETAL or NEUROLOGIC.
No - he spelled it the second time and added a hyphen ...
Subject: No - he spelled it the second time and added a hyphen ...
mega-gastrium. (But we all know how well they spell sometimes.) TGIF!
Got it - hypothenar - doctor added an 'ic'
Subject: Got it - hypothenar - doctor added an 'ic'
Could be abbreviating neutralizer like bicarbonate being added. nm
Subject: Could be abbreviating neutralizer like bicarbonate being added. nm
s
Glad to help. I added the mesh to my list. nm
Subject: Glad to help. I added the mesh to my list. nm
TY! copied and pasted and added to favs...nm
Subject: TY! copied and pasted and added to favs...nm
x
You added "with" after status, not necessarily
Subject: You added "with" after status, not necessarily
x
I'm thinking something like a "neck roll" added to
Subject: I'm thinking something like a "neck roll" added to
bed to elevate her head - just a guess
I am allowed to restate as 4 10/12-year-old child
Subject: I am allowed to restate as 4 10/12-year-old child
but my account is like that. Ask your QA person what the account wants JMO
Whoa! Not allowed to ask innocent questions here?
Subject: Whoa! Not allowed to ask innocent questions here?
Veddy interesting.
Name calling is not allowed on MT Stars. Where's our moderator now? Where RU??? Yoo-hoo! (N
Subject: Name calling is not allowed on MT Stars. Where's our moderator now? Where RU??? Yoo-hoo! (NM)
LOL.
Thanks...that option is not allowed as my account is verbatim...
Subject: Thanks...that option is not allowed as my account is verbatim...
I put the word in as dictated with quotes around it and then sent it off to QA. I noticed later that they just deleted it and put a blank and sent it through without the word. Yet one more reason why I hate being on verbatim accounts!
I would expand it to saturating or saturations if allowed. nm
Subject: I would expand it to saturating or saturations if allowed. nm
s
Why aren't students allowed to ask questions?
Subject: Why aren't students allowed to ask questions?
From what I understand anyone can ask a question, including doctors, nurses, techs, etc. I don't understand why you are telling the OP she cannot ask a question here? 
I would type Sr. so-and-so if you're allowed pt names. nm
Subject: I would type Sr. so-and-so if you're allowed pt names. nm
nm
No test question posts allowed here....
Subject: No test question posts allowed here....
.
I have it dictated as "no added heart sounds"...nm
Subject: I have it dictated as "no added heart sounds"...nm
nm
If allowed, I would reword this...possibly, has not redeveloped a bleed.
Subject: If allowed, I would reword this...possibly, has not redeveloped a bleed.
/
Agree with Skipper, though, if allowed, restructuring the sentence would be better. nm
Subject: Agree with Skipper, though, if allowed, restructuring the sentence would be better. nm
x
Are test questions allowed on the Word Board?
Subject: Are test questions allowed on the Word Board?
Just wondering, for future reference. :)
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