I am transcribing a report
Posted By: Siren on 2008-02-25
In Reply to:
Subject: I am transcribing a report
on a child. The doctor is stating that she gave s/l 2 to 1 neb? Is this what I am hearing? TIA
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I am transcribing
Subject: I am transcribing
That is a very good point. I will type it the way she dictates. Thanks for the help.
no, maybe not - maybe they're transcribing ESL doc
Subject: no, maybe not - maybe they're transcribing ESL doc
are you transcribing or coding?
Subject: are you transcribing or coding?
If you are transcribing, the correct way is:
V code: Parent-child conflict.
Unless you are a certified coder, it would be wise to avoid inserting the actual code into the transcription as the MD/psychologist did not dictate it. The codes can change from year to year and you could enter the wrong code depending on the date of the service and which coding resource you are using.
I have been transcribing "supertherapeutic." (sm)
Subject: I have been transcribing "supertherapeutic." (sm)
super = excess, above, but often the same usage as "supra." (Stedman's).
Are you by chance transcribing a dictation of Dr. A. S?
Subject: Are you by chance transcribing a dictation of Dr. A. S?
help transcribing measurement STAT
Subject: help transcribing measurement STAT
I know that I know this somewhere in my head, but I can't think of it to save my life
How do I transcribe "twelve one-hundreths of an inch"?
TIA!!
Advice for transcribing lens
Subject: Advice for transcribing lens
I am new and have an ophthalmology account. I am not having much trouble with the terms, but I'm unsure how to punctuate and/or format the lens prescriptions. Does anyone know of a good website that explains this or provides examples? Thanks!
Thank you so much! I now realize I have at times been transcribing wrong. nm
Subject: Thank you so much! I now realize I have at times been transcribing wrong. nm
!
I never heard strandy until I started transcribing sm
Subject: I never heard strandy until I started transcribing sm
for one of my current radiologists. He says "strandy" plain as day, so that's what I put. Grates on my nerves, but he's the radiologist.
When transcribing "Sister so-and-so, when dictator refers
Subject: When transcribing "Sister so-and-so, when dictator refers
to patient as "sister" throughout report, is "sister" capitalized or not? Neither way looks correct to me.
To be perfectly honest, I have never seen it with periods before and I have been transcribing for 34
Subject: To be perfectly honest, I have never seen it with periods before and I have been transcribing for 34 years, but I too still have to learn new things every day. Guess that is what keeps me motivated.
transcribing about NIDDM. Sounds like sulfanuria and glybizone.
Subject: transcribing about NIDDM. Sounds like sulfanuria and glybizone.
I've come across a dictation that is talking about NIDDM. It sounds like he's saying "he was initially of sulfanuria and switched insulin in Puerto Rico". The other part is "He has never been on metformin or glybizone." Any suggestions??
In eight years of transcribing ortho, I've never heard this term...
Subject: In eight years of transcribing ortho, I've never heard this term...
Impression:
1. Left de Quervain tendinitis.
2. Left carpal tunnel syndrome.
Will get EMGs. The patient has evidence of s/l palmarthrorheumatosis. He runs it together, so it may be palm (or palmar) arthrorheumatosis.
Any help is appreciated. :)
Correction: Cytotec (ulcer med).It's the lateness of the hour. Thought I was transcribing alone.
Subject: Correction: Cytotec (ulcer med).It's the lateness of the hour. Thought I was transcribing alone.
x
Transcribing ESL. He is pretty clear, but does 15 cc fluid restriction sound a little severe??? (nm)
Subject: Transcribing ESL. He is pretty clear, but does 15 cc fluid restriction sound a little severe??? (nm)
x
when transcribing "baby girl Smith" should baby girl be capitalized?
Subject: when transcribing "baby girl Smith" should baby girl be capitalized?
We have been caught by our QA for transcribing Toprol XL instead of Toprol-XL Since there is
Subject: We have been caught by our QA for transcribing Toprol XL instead of Toprol-XL Since there is
technically not a drug called Toprol should this be transcribed as Toprol-XL though dictated as only Toprol. Have not been called on this yet, but just wondering what others do.
EKG report
Subject: EKG report
"No weeshnoblomotion abnormalities are identified." What is that word?
thanks everyone. One more report and then I am going to bed.
Subject: thanks everyone. One more report and then I am going to bed.
nothing more to add about the report unless
Subject: nothing more to add about the report unless
the patient had an implanted pacemaker which is not eluded to here. Just a note, adenosine is not capitalized except to start a sentence.
Maybe you will hear something back.
d~
Sorry, same report...
Subject: Sorry, same report...
"CPK and _______ were negative" s/l intraconals??
Still on the pulmonologist's report...
EEG report
Subject: EEG report
Anyone ever heard of an EEG performed on a Nikon Codon machine? Thanks.
just sent the report on.........nm
Subject: just sent the report on.........nm
x
op report sm
Subject: op report sm
What kind of surgery is it? If he used "lap" laparotomy pads may be the second one. They usually say sponge, needle and instrument counts. Will keep thinking on this one. Type of surgery would help.
You don't say where in the report -- sm
Subject: You don't say where in the report -- sm
this is given, or any other context, so I have to wonder if this isn't a problem list perhaps giving more than one diagnosis/problem here (as in (1) portosystemic shunt and (2) nephrolithiasis)...
Just a thought
ENT report - sm
Subject: ENT report - sm
Does include sinus surgeries, Caldwel-Luc surgery. Is also on Flonase. Patient is actually here regarding Grave's disease. I'm wondering if this is Relpax D, but I'm not able to verify that as a drug. Any suggestions?
ENT OP report help, please...
Subject: ENT OP report help, please...
Vocal cord lesion biopsy -
Peripheral -s/l orb or oral- sinuses were intubated to their apices and were normal.
Specimen was sent -s/l informal- and for pathology.
TIA!
OP report
Subject: OP report
OP report, lumbar spine
Next, fluoroscopy was used to place new screws at the L2-3 segment. Starting points were identified at the confluence of the midpoint of the transverse process, the **manloid** process, and the pars interarticularis
He really mumbles through this part, so I am just not sure, but I have not heard this term used before. Thanks!
op report help please sm...
Subject: op report help please sm...
FINDINGS: Epidurogram revealed normal (s/l-cephaloquadet-) contrast flow outlining the right L5 nerve root sleeve in the epidural space with good flow achieved medial to the right L5 pedicle. The patient did experience some concordant L5 symptoms on the right side during the injection. Vital signs remained stable throughout.
OP Report
Subject: OP Report
Hi all! I am doing an OP for a lumbar spine surgeon, but this is just for an I&D. He says the area was probed with "sucker tips" and was found to be subfascial. I am not too comfortable with what I am finding online for this. Has anyone heard this before? Thanks!
OP report help, please
Subject: OP report help, please
Patient was premedicated with intravenous s/l Benadryl.
Would that be right?
report does not say .. but says she is on BC
Subject: report does not say .. but says she is on BC
help with op report
Subject: help with op report
I never do op notes! The sentence reads:
The S/L RAFFAY between the anterior and middle deltoids was then opened. TIA!
Doing EMG report sm
Subject: Doing EMG report sm
The patient has focal severe slowing primarily in sensory fibers in the right upper extremity, on multiple restimulation unable to elicit a response to both s/l "Palmar 8" studies.
I can't find this anywhere. Anybody have any ideas? Thanks!
I wish I could see the report, but
Subject: I wish I could see the report, but
could she be saying communication, as in an opening has formed between 2 sinuses or something?
It is so frustrating to be given only a tidbit of a report instead of being able to puzzle it out from what is going on with the patient.
Thanks, but as I'm into the report it
Subject: Thanks, but as I'm into the report it
sounds like this is some weird wording for microscopic blood.
I've done thousands of endoscopy reports and GI consults, but I can't think why he'd say "affobiddy positive stool" instead of something about occult blood or microscopic blood.
ER report. Sm please
Subject: ER report. Sm please
The patient has a 4 mm calcification on the pelvis on the right which may represent a s/l flevolith, thus a right ureteral calculus could not be entirely occluded.
OP report
Subject: OP report
general s/l elam anesthesia. New to OP reports! TIA
Thanks! That's how I did it in the report nm
Subject: Thanks! That's how I did it in the report nm
OP report
Subject: OP report
s/l -fecal lift- at the base of the appendix
C-sec report
Subject: C-sec report
Does this by some chance have to do with cephalodisproportion, because I looked up Jill Cohen - C-section in google, and there is somebody named Jill Cohen and it talks about labor and delivery and C-section and something this lady wrote about it. Could this be it. Check it out on google.
PT report
Subject: PT report
S/l ESTEEM for pain management?
report
Subject: report
Does any one know focal tics of sounds like aphitical movements. Thank could use the help.
TEE report - Need help
Subject: TEE report - Need help
" NO BUBBLES ___________ FROM RIGHT TO LEFT SIDE" s/l caused. He also said bubble study was done with 9 mL normal saline and "a cc" of air. Is this written 1 mL?
per report
Subject: per report
The only diagnosis is bipolar, duh!
was my last report of the day
Subject: was my last report of the day
and he was getting to me! my least favorite account, lots of bad dictators
MRI report s/m
Subject: MRI report s/m
MRI of the brain shows what looks to be an acute infarct on DWI on the right brainstem area, which were also changes seen on the T2 weighted - s/l anuses - suggesting that this is probably an infarct, which occurred 7-10 days ago.
any ideas cuz I'm pretty sure there are no weighted "anuses" in the brain, at least not identifiable by MRI.
op report help
Subject: op report help
Doc states that the the articular surface of the lateral tibial plateau was then s/l stacked as was the weightbearing surface of the lateral femoral condyle.
Thanks
It's an EGD report .... sm
Subject: It's an EGD report .... sm
He states, "Instruments used were a Fujinon esophagogastroduodenoscope and a ________ bougie #54."
He later states, "The ________ bougie was passed easily."
GU op report help please
Subject: GU op report help please
I tried to dilate the urethra with s/l male sounds, but they would not pass easily due to the false passes. (Talking about bladder stones).
He says it clearly, but I've never heard of these nor can I find it. Can't find anything under "Mayo" either thinking perhaps it was an instrument of some kind.
GU op report help please
Subject: GU op report help please
Could it be Dittel?
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