History & Physical Headings
Posted By: Thequeen on 2008-12-26
In Reply to:
Subject: History & Physical Headings
I am trying to head a H & P what do I list the bladder and groin under?
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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?
H & P- history and physical...nm
Subject: H & P- history and physical...nm
m
History and physical word help
Subject: History and physical word help
The doctor say chief complaint, S/l appendidiver HPI... Any suggestions? Thanks for everyone's help..
maybe admission H&P (history and physical). NM
Subject: maybe admission H&P (history and physical). NM
x
Should history and physical be capitalized?
Subject: Should history and physical be capitalized?
Sentence reads p/t is here today for a complete history and physical...... Should history and physical be capitalized? Thanks.
Neurological History and Physical
Subject: Neurological History and Physical
This is going to probably sound crazy....but it s/l "whirring imbalance."
Might just be the History and Physical that's back at the office, or the H&P. nm
Subject: Might just be the History and Physical that's back at the office, or the H&P. nm
s
Neurological History and Physical Exam
Subject: Neurological History and Physical Exam
Any help on this would be appreciated. This is a neurology history and physical and the doc is dictating the Assessment/Plan. She states, "This patient with a _________ imbalance. She did have normal imaging before, but did not get a MRA". My brain is mush and I just cannot understand what type of imbalance she is referring to. Thank you for any assistance.
HOSPITAL COURSE: Fish?? admission history and physical for details
Subject: HOSPITAL COURSE: Fish?? admission history and physical for details
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.
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?
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
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?
Headings are allowed to be added.
Subject: Headings are allowed to be added.
It would look weird without a heading. Thanks.
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
Physical exam
Subject: Physical exam
Height: Six feet.
I'm having trouble remembering all my rules on numbers for stats and such. Is this right? Thank you.
On physical exam.. S/L
Subject: On physical exam.. S/L
or maybe slight disks bilaterally? I'm drawing a blank... HELP PLEASE and THNX!
Physical exam
Subject: Physical exam
The doctor dictated "no jugular venous distension at 30 degrees" under heart of the physical exam. Shouldn't it go under neck? Thank you.
physical exam-GU
Subject: physical exam-GU
obese 9 year old--phallus difficult to examine as the patient has a large sl-paptha- and has a concealed phallus.
re physical exam
Subject: re physical exam
PHYSICAL EXAMINATION: Significant findings for left lower quadrant tenderness. Blood pressure was 124/78, pulse rate of 96, and respiratory rate of 20. Heart: S1 and S2. Lungs: Clear to auscultation bilaterally.
I would type it this way or at least make it present tense. On my accounts, I am required to categorize these things.
PHYSICAL EXAMINATION:
Abdomen: Significant findings for left lower quadrant tenderness. Vital signs: Blood pressure 124/78, pulse rate 96, respiratory rate 20. Heart: S1 and S2. Lungs: Clear to auscultation bilaterally.
GI physical exam
Subject: GI physical exam
In the physical exam, s/l thenar and epithilial wasting. He is listing liver disease stigmata and I just blanked out on this. Help!
This is on physical exam
Subject: This is on physical exam
thanks for trying.
physical exam help
Subject: physical exam help
Physical exam, under Extremities, doctor states ___ pulses throughout.
It sounds like temporis pulses. I know of temporal pulses, but would that be throughout the extremities? Thank you!
Physical exam help?
Subject: Physical exam help?
EXAMINATION: No costovertebral angle tenderness. Abdomen has normal active bowel sounds in all quadrants. It is supple. Extremely tender left upper quadrant and going down not quite into the groin. Difficult to check the (s/l sternal) border because of increased tenderness but the spleen may be mildly enlarged but no distinct masses felt. I am unable to check for rebound or guarding because she is so exquisitely tender with even a very light touch.
ASSESSMENT: Acute left upper quadrant pain.
s/l sternal border? Any help would be great?
physical exam
Subject: physical exam
Probably just means + (the plus sign), as in positive S1, S2...just means he heard 1st and 2nd heart sounds clearly (as opposed to sounds to distant or obscured by extra sounds). If something was dictated before that, I would put a comma and use the plus sign, i.e., PREVIOUS TEXT, + S1, S2. If nothing precedes it, I would type positive S1, S2. If account wants verbatim, give it to them.
It was just a physical exam, and I don't know
Subject: It was just a physical exam, and I don't know
However, I do think it was "cervical or" inguinal adenopathy. This guy is a real mush mouth. THANK YOU ALL SO MUCH FOR YOUR HELP! I am sorry I wasn't clear enough earlier in my first message. I really do appreciate your help. This is a great board to come to--everyone is so knowledgeable!
Need help with physical exam please
Subject: Need help with physical exam please
I am wondering if, in the last sentence, where "drop can arc" is dictated . . . would she be referring to three tests/maneuvers such as Drop Arm, Empty Can, and an Arc test, or is it correct as is?
She has excellent range of motion of the shoulder. Good grip strength. Distal pulses and sensation are intact. She can do a full drop can arc.
TIA
Please help with physical exam (sm)
Subject: Please help with physical exam (sm)
Over the central aspect of the wound there is s/l shelfing of the superior aspect of the skin
This is in the physical examination. Thanx for trying
Subject: This is in the physical examination. Thanx for trying
Physical examination... sm
Subject: Physical examination... sm
Examination of female patient.
Musculoskeletal: No (s/l) keps, pains, or pedal edema...
Genitourinary: No (s/l) [cussforteeballing or maybe cusp or teeballing], or area tenderness.
Thanks in advance!
Physical exam help.....
Subject: Physical exam help.....
The calf was nontender. The lower leg was s/l nonpeeing. Nonpitting? Not pitting? Help, please!
Physical Examination
Subject: Physical Examination
Happy Monday everyone! Hope you all had a great weekend! I'm doing a report and wondering if any of you can point me in the right direction!
"There is good capillary refill and s/l preson to cultures over both lower extremities." Any thoughts? Any good physical examination websites?
Physical exam help
Subject: Physical exam help
HEENT: It sounds like she is saying 'TO' mucosa pink and moist. Or TL mucosa.
Any ideas?
Under physical exam...
Subject: Under physical exam...
I know this is probably really easy...BUT, the doc is rattling it off and he's new to me...
ABDOMEN: Soft, nontender, nondistended, ___ to bowel sounds.
Is it normal to bowel sounds?
Thanks....
yes, physical therapists
Subject: yes, physical therapists
What do you mean by PTs? Physical therapists?
Subject: What do you mean by PTs? Physical therapists?
.
s/l physical examination
Subject: s/l physical examination
s/l chaos lesions (Skin, no evidence of ___ lesions)
Physical Exam
Subject: Physical Exam
s/l duprichen contractions of both hands
Physical exam
Subject: Physical exam
New acct. Dr. states: Lungs were congested with s/l "rasmus" Any ideas? Thanks for the help.
physical exam
Subject: physical exam
thanks ss. Unfortunately, not rales or rhonchi. He dictates that quite often and it sounds nothing like it! I might be stuck on this one.
physical exam help
Subject: physical exam help
Patient converses in appropriate (s/l fashion _____ only). She is s/l confident imminently or eminently. Does this make sense??
physical exam help
Subject: physical exam help
He starts off Temperature 98, heart rate 73, then goes on to just list numbers like 20, 46/70, 91%. Do some doctors just list the numbers without the words. I am assuming it is the respirations and BP and maybe oxygen sat.
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