Hmmm. Dunno. Is it repeated in the plan section of the report? sm
Posted By: nm on 2006-07-18
In Reply to: s/l muns maybe interventional therapy?? - Laura
Subject: Hmmm. Dunno. Is it repeated in the plan section of the report? sm
It may just be a little English word.
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She just repeated it again further down in the report
Subject: She just repeated it again further down in the report
and clearly said Lamborghini. Plain as day! Guess I'll just flag it.
Yes. It is likely the report from a frozen section. NM
Subject: Yes. It is likely the report from a frozen section. NM
Not sure but comprehensive 65 plan, may be referring to age/healthcare plan?
Subject: Not sure but comprehensive 65 plan, may be referring to age/healthcare plan?
Sorry, tried to help. Have a nice weekend.
quick section (as in frozen section) is correct.
Subject: quick section (as in frozen section) is correct.
x
Geeze sorry. She repeated it later it is actually....sm
Subject: Geeze sorry. She repeated it later it is actually....sm
Patellofemoral syndrome. She is in too big a hurry to slow down.......
Do you have a med list on him? Is it repeated
Subject: Do you have a med list on him? Is it repeated
s
Help with a word repeated in the note.
Subject: Help with a word repeated in the note.
hepatic congestive ?? s/l hyp-oth-opathy
In a patient with increased LFTs. Thanks.
So sorry I jumped the gun, he repeated it shortly after...
Subject: So sorry I jumped the gun, he repeated it shortly after...
It is lateral mass screws. This report is due quickly, so I got in a hurry. Thank you!!
See, I told you it has been a long day. I repeated myself. LOL
Subject: See, I told you it has been a long day. I repeated myself. LOL
C-section or cesarean section sm
Subject: C-section or cesarean section sm
Not cAesarean section - contrary to popular belief, it was not named after Julius Caesar.
C-section or cesarean section nm
Subject: C-section or cesarean section nm
nevermind it's 'off' axis. He repeated it in the impression much more clearly!
Subject: nevermind it's 'off' axis. He repeated it in the impression much more clearly!
Patella baja (no r) Dr. repeated large or spelled.
Subject: Patella baja (no r) Dr. repeated large or spelled.
I dunno......(nm)
Subject: I dunno......(nm)
/
dunno but maybe Omega-3, B12....???
Subject: dunno but maybe Omega-3, B12....???
I'm not sure - just guessing - people do take Omega-3 either via fish food or fish oil pills so I'd give them O-3, B12............or blank the O-3 
dunno but sometimes they say A2 greater than P2...
Subject: dunno but sometimes they say A2 greater than P2...
I dunno--Caduet maybe?
Subject: I dunno--Caduet maybe?
But it's not for BPH...it's for hypertension and hyperlipidemia (I think).
gm may be for gram..dunno about MT
Subject: gm may be for gram..dunno about MT
/
(that's 2 2 2 Solution- dunno why it became a ?)
Subject: (that's 2 2 2 Solution- dunno why it became a ?)
first one: atelectasis, second one dunno (nm)
Subject: first one: atelectasis, second one dunno (nm)
there's Xeloda --- dunno (nm)
Subject: there's Xeloda --- dunno (nm)
pt has hypercalcemia..A bone density test will be repeated in therapy with a bisphosphonate & sm pls
Subject: pt has hypercalcemia..A bone density test will be repeated in therapy with a bisphosphonate & sm pls
A bone density test will be repeated in therapy with a bisphosphonate and s/l sit-ter-rid
The med could be ceftriaxone...dunno about the abcess. nm
,
dunno about most but it's tube feeds, not ....n/m
Subject: dunno about most but it's tube feeds, not ....n/m
@
Dunno, but it's always drawer for the knees. nm
Subject: Dunno, but it's always drawer for the knees. nm
s
peas? bees? Dunno what else. nm
Subject: peas? bees? Dunno what else. nm
s
dunno sorry - but it's prednisone (small p)
Subject: dunno sorry - but it's prednisone (small p)
I don't abbreviate but if verbatim, I guess a-fib or A-fib. Gee. I dunno because SM
Subject: I don't abbreviate but if verbatim, I guess a-fib or A-fib. Gee. I dunno because SM
I just don't use slang words in my transcription. I hate those vertabim accounts, don't you?
It's arcade of Frohse, dunno about Henry. nm
Subject: It's arcade of Frohse, dunno about Henry. nm
nm
Wonky doc clearly said dolic astolic CHF. I dunno either.
Subject: Wonky doc clearly said dolic astolic CHF. I dunno either.
Plan
Subject: Plan
CBC with differential, type and cross for 20 units, electrolytes P3, P4, PT, PTT, EKG, PA and lateral chest pulmonary function test.
I'm just in school for Med Trans. I love this website. I'm always confused when it comes to listing labs. I need help on the above. Thank you so much.
Plan help please!
Subject: Plan help please!
I am a new, and need some help. after the doctor says plan he lists the medications he has prescribed. He does not number them and I am used to them saying medications and then listing (1, 2, 3) Do they usual do that? Should I leave it like he says it? Example:
PLAN:
Ecotrin 1 p.o. b.i.d. with meals. Keflex 500 mg p.o. q.i.d. for 4 days.. Follow-upl with me within the next 10 days.
thanks!
Plan help please!
Subject: Plan help please!
That all depends on the QA person reviewing the report.
I have been told both are correct and both are wrong, other than if there is only one item (in which case you never number).
I have been audited and smacked down (points) for NOT numbering when the dictator did not number on meds and on diagnoses, etc., even on a verbatim account. I would love if someone could explain why. The client profile for the account says "do not number" if the dictator does not number.
Plan.... UA and CNS or C&S?? thank you
Subject: Plan.... UA and CNS or C&S?? thank you
Do you have to have a plan?
Subject: Do you have to have a plan?
Where I work, if they don't say "plan", they don't get a "plan".
That's what I plan to do.
Subject: That's what I plan to do.
I do not like to guess. Now it says for prostate cancer, so it might be. I will just flag it and put a s/l, just in case. I don't want them to think I didn't try to look it up either.
Pt. with fistulogram. A s/l Growin towel tape was placed and I repeated the fistulogram.
Subject: Pt. with fistulogram. A s/l Growin towel tape was placed and I repeated the fistulogram.
I'm brain fried about this time. Anyone?
Here's another one: Under Assessment/Plan
Subject: Here's another one: Under Assessment/Plan
1. Erythrocytosis – the patient did have a hemoglobin of 17 on blood work one year ago. I asked him to repeat it, but he forgot. We will recheck his CBC with NORRIS REPREEDIN level today and work this up accordingly. He is not symptomatic.
I keep listening over and over to this, and this is all I can make out. Any clue what he might be referring to??? TIA
assessment&plan help!
Subject: assessment&plan help!
If the doctor says assessment and plan together, do I put the header together? I am confused because when he gives the assessment he numbers them 1) 2) then when he gives the plan he numbers them as well but does not say plan any help?
ASSESSMENT:
- Bilaterally arm numbness.
- Nausea.
- Health maintenance recommendations.
PLAN:
- Patient’s critical examination was hyperreflexia suspicious for possible cervical lesion. She will be referred for MRI with cervical spine. Patient may need EMG to further access her numbness.
- Patient will be tried on Nexium, although she does not have any overt symptoms of heartburn. She does have chronic nausea and this may be a sign of stomach reflux. She will be tried on Nexium 40 mg one q.d. Other diagnostic possibilities include slow gastric emptying. The patient does not eat breakfast or lunch and has her largest meal at about 8:00 at night. We discussed the need to consume breakfast and ideally eat 3-5 meals per day, smaller meals to encourage her metabolism. ___ problem health maintenance and in regards to increase her exercise and changing her diet. Patient will be referred to OB/GYN for Pap and pelvic and also will be referred for a screening mammogram. When she follows up to see me we will discuss potential options for colon screening. Patient is to follow-up with me in approximately 1 month time.
assessment and plan
Subject: assessment and plan
I hate when docs do that - mine do it a lot. I think you're good either way but I would put "A&P" as the heading and then just type it the way the doc says it.
starts plan
Subject: starts plan
it starts the plan then says ??? flonase 2 sprays each nostril
Sounds like a plan to me!!
Subject: Sounds like a plan to me!!
Thanks!!
s/l her-plan-jet-ick lesions
Subject: s/l her-plan-jet-ick lesions
s/l her-plan-jet-ick lesions in the mouth and throat
this is a 17 month old with excessive drooling and fever.
that sounds like a plan
Subject: that sounds like a plan
nm
Is this directions for something or what? A plan at the end of a scan? nm
Subject: Is this directions for something or what? A plan at the end of a scan? nm
s
In plan he very plainly says says need to rule out
Subject: In plan he very plainly says says need to rule out
Patient fell and injured right ankle. Sentence in question: She is significantly tender in the s/l coronal ligament s/l and the (or in the) right ankle.
Plan: MRI to rule out coronal ligament tear.
This is very clear - just cannot document it anywhere and don't want to flag it as it's very clear - just unsure and hoping for documentation or someone that has heard it.
Where would you begin the PLAN if the dictator does not say so?
Subject: Where would you begin the PLAN if the dictator does not say so?
ASSESSMENT: We discussed options for Jeff. At this point, a month after the injury, an MRI, potential surgical interventions, etc., ultimately doing as well as he is, he is just going to keep it in mind and be careful with his lifting. He drives a forklift, apparently on a regular basis, but we are going to forego further work up at this point. We also got int a discussion of routine health care maintenance. He will plan on complete physical in October, starting this year. I will put a standing order at lab at this point for him, for a UA basic metabolic fasting lipid panel and PSA. We will go from there.
Help with sentence. This is doc's treatment/plan: sm
Subject: Help with sentence. This is doc's treatment/plan: sm
The sentence just doesn't seem right to me. Any input appreciated!
" Examination, evaluation, simple avulsion nail plate, 3rd left lateral aspect nail plate avulsed paronychium performed under anesthesia."
Plan: Check CMP and s/l iris ads
Subject: Plan: Check CMP and s/l iris ads
In plan, doc says check s/l FH LSH. How would this be typed --
Subject: In plan, doc says check s/l FH LSH. How would this be typed --
plan of coagulation? planned? WAG
Subject: plan of coagulation? planned? WAG
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