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I believe the are 2 separate diagnoses and would transcribe as such.

Posted By: giddy pc guru on 2007-02-02
In Reply to: IMPRESSION prob - yuneci

Subject: I believe the are 2 separate diagnoses and would transcribe as such.

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when the doc does this, I usuall separate with a forward slash if there are no other diagnoses...nm
Subject: when the doc does this, I usuall separate with a forward slash if there are no other diagnoses...nm

x
They are separate. sm
Subject: They are separate. sm

The common bile duct is the duct formed by the union of the cystic duct (from the gallbladder) and the hepatic duct, which is formed by the intrahepatic biliary tree.
Separate them. nm
Subject: Separate them. nm

s
It should be separate, SAD/DCR or SAD-DCR, or SAD, DCR
Subject: It should be separate, SAD/DCR or SAD-DCR, or SAD, DCR

Shoulder arthroscopic debridement and distal clavicle resection.  Gotta love these docs and their neverending shortcuts, just lazy behinds. LOL


No they do not go together. Separate
Subject: No they do not go together. Separate

x
I personally would just separate
Subject: I personally would just separate

by a slash 500/500/250/500, but that's just me :)
Could he mean separate consult?
Subject: Could he mean separate consult?


Ugh..can you separate your s/l into syllables for us, please? Thx. nm
Subject: Ugh..can you separate your s/l into syllables for us, please? Thx. nm

s
Well, BOS pg 12 says use a comma to separate 2 or
Subject: Well, BOS pg 12 says use a comma to separate 2 or

v
Can you separate your s/l into syllables for us? nm
Subject: Can you separate your s/l into syllables for us? nm

s
Yes, 2 separate items. nm
Subject: Yes, 2 separate items. nm

s
No they are three separate views.
Subject: No they are three separate views.

No they are 3 separate views.
It is the sentence structure that is confusing. Three individual views, but once the word views gets put into the sentence it becomes plural and without the word views it is regarded as singular. I don't necessarily agree, but I believe this is why the QA department and your manager keep changing your grammar.
I believe tumor is separate...
Subject: I believe tumor is separate...

"s/l H nerve, tumor, or other..."
I keep them separate, i.e. mid portion.
Subject: I keep them separate, i.e. mid portion.

x
Seems like that goes with Nystatin and not a separate drug -
Subject: Seems like that goes with Nystatin and not a separate drug -

x
it is prothrombin time, to separate....sm
Subject: it is prothrombin time, to separate....sm

When it is really prothrombin time, it makes NO sense to type pro time as 2 words....I really don't care what BOS says about this one particular issue.  The word really is prothrombin time and MDs say protime....I give them protime.  Just my take on it. 


Sorry. Put answer on separate entry. nm
Subject: Sorry. Put answer on separate entry. nm


Could your s/l be something separate from "cardiac disease," sm
Subject: Could your s/l be something separate from "cardiac disease," sm

such as whatever it is, cardiac disease, and congestive heart failure. Any clues in the rest of report?

This has got me stumped.
Are you hearing this with an accent? Can you separate it into
Subject: Are you hearing this with an accent? Can you separate it into

s
Also, with the periods it would be 3 separate words, which it is not...
Subject: Also, with the periods it would be 3 separate words, which it is not...

cerebrovascular accident always has been CVA (hard to keep up with so many new rules).
can only find two separate angles. sm
Subject: can only find two separate angles. sm

metatarsus adductus angle, and intermetatarsal angle.  You probably already knew that, and it probably doesn't help decipher what your doc really means.
2 separate vital signs nm
Subject: 2 separate vital signs nm

nm
I agree, 3 separate things. nm
Subject: I agree, 3 separate things. nm

.
If not dictated separate, then combine.
Subject: If not dictated separate, then combine.

x
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
Just means 2 separate entities. It would fit. Or maybe it's "continued?" nm
Subject: Just means 2 separate entities. It would fit. Or maybe it's "continued?" nm

s
maybe "sent separately" - as in a separate specimen
Subject: maybe "sent separately" - as in a separate specimen


The doc says, through a separate subfascial skin incision when...sm
Subject: The doc says, through a separate subfascial skin incision when...sm

harvesting iliac crest during a spinal fusion. It doesn't make sense to me. I would think it would need to be either a separate subfascial incision or a separate skin incision. I have never heard it described this way before and I don't think it makes sense his way.
I have always used and seen S1, S2, two separate heart sounds during auscultation......nm
Subject: I have always used and seen S1, S2, two separate heart sounds during auscultation......nm

nm
I have always used and seen S1, S2, two separate heart sounds during auscultation......nm
Subject: I have always used and seen S1, S2, two separate heart sounds during auscultation......nm

nm
antinuclear antibody is separate test from CBC...sm
Subject: antinuclear antibody is separate test from CBC...sm

may be saying antinuclear antibody assay and CBC? 
Pretty sure they're two separate problems. nm
Subject: Pretty sure they're two separate problems. nm


Thanks so much! I knew of the two separate, but questioning myself on something I didn't know.
Subject: Thanks so much! I knew of the two separate, but questioning myself on something I didn't know. Thx


They're all likely related, but I'd personally do 3 separate dxs. n/m
Subject: They're all likely related, but I'd personally do 3 separate dxs. n/m


In the sentence you describe, I would not separate by common and use v or vs instead, as cited by...
Subject: In the sentence you describe, I would not separate by common and use v or vs instead, as cited by...

Cambridge Dictionary:


(WRITTEN ABBREVIATION v or vsused to compare two things or ideas, especially when you have to choose between them:
i.e., private education versus state education



 


Yes, but if lab stuff, try and separate the "components" if you're sure of them with semico
Subject: Yes, but if lab stuff, try and separate the "components" if you're sure of them with semicolons or

s
This is grip strength bilaterally. The others were on separate hands.
Subject: This is grip strength bilaterally. The others were on separate hands.


I think it is only the diagnoses that need....
Subject: I think it is only the diagnoses that need....

to be spelled out. This part is more like the plan.
diagnoses
Subject: diagnoses

Axis I - VI are not arms of one diagnosis, but of many diagnoses, in different systems and considerations. They include psychiatric diagnoses, functional diagnoses, physical illness diagnoses, etc., etc.
Diagnoses...
Subject: Diagnoses...

Croup and bronchitis.

Procedures: nasogastric tube feed and OPM study. Also says that OPM study indicated silent aspiration.
Any other diagnoses?
Subject: Any other diagnoses?


diagnoses
Subject: diagnoses

Debility.


Dementia with acute confusional state.


Abrasion to shoulder.


Metastatic disease.


Dehydration.


End-stage COPD.


Arthritis.


SIADH.


Hypokalemia.


Hyponatremia.


Bowel obstruction, etiology undetermined.


Urinary tract infection.


Septic condition of blood.


 


diagnoses
Subject: diagnoses

Diagnoses as follows:

paroxysmal atrial fibrillation, end-stage renal disease, Lown-Ganong-Levine syndrome, hypertension, hypopituitarism, acromegaly, hyperparathyroidism, hypothyroidism, insulinoma.

does that help?
Diagnoses....
Subject: Diagnoses....

Hypertension, chronic edema, hypothyroidism, pacemaker placement, mitral valve prolapse, DVT, hyperlipidemia, GERD, proteinuria, right-sided heart failure

No, see diagnoses. Thanks.
Subject: No, see diagnoses. Thanks.

1.  Acute left chest pain.


2.  Esophagitis.


3.  Coronary artery disease.


4.  Hypertension, severe.


5.  Probable renal artery stenosis.


6.  Peripheral vascular disease.


7.  AKI.


8.  Malnutrition.


9.  Anemia.


Two diagnoses nm
Subject: Two diagnoses nm

k
are these diagnoses...
Subject: are these diagnoses...

correct? He rambles them all together, not sure if I am correct with what I am hearing.

DIAGNOSES:
1. HARDWARE PAIN, RIGHT SECOND METATARSAL FUSION WITH A HISTORY OF DEEP INFECTION AFTER HAMMERTOE PROCEDURE, RIGHT SECOND TOE
2. PAIN AFTER KNEE REPLACEMENT
3. PAIN, LEFT FOOT

tia.
is this 2 or 3 diagnoses?
Subject: is this 2 or 3 diagnoses?

DIAGNOSES:
1. LEFT KNEE LATERAL MENISCUS TEAR
2. OSTEOCHONDRAL DEFECT
3. RIGHT KNEE DEGENERATIVE JOINT DISEASE

Not sure if Right knee degenerative joint disease should be number 3. tia.
I should have put the diagnoses which are..
Subject: I should have put the diagnoses which are..

1. GOUTY ARTHROPATHY
2. NEURALGIA PAIN
3. FAT PAD ATROPHY

Would it still be hallux shoes and also if so would Hallux be capitalized? Thanks for your help.

on diagnoses -diseases
Subject: on diagnoses -diseases

DISCHARGE DIAGNOSES



  1. Relapse acute myelomonocytic<soundslike> leukemia.

  2. Severe pancytopenia due to bone marrow hypopasia secondary to cancer chemotherapy.

  3. Sepsis, possibly due to  staphylococcus lubdenensis.

  4. Ogroshong<soundslike> catheter exit site infection.

  5. Hypocholemia.

Any diagnoses for the patient? nm
Subject: Any diagnoses for the patient? nm

s