I cheat and change it to 'nursing notes.' sm
Posted By: Confetti on 2008-11-26
In Reply to: Nurses' notes or nurse's notes or nurses notes? - KMS
Subject: I cheat and change it to 'nursing notes.' sm
I could never figure out which one was correct and asking anybody at the company would surely give 2 different answers. I've never once been dinged for changing it to nursing notes, probably because the editors can't agree which of the others is correct.
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Nurses' notes or nurse's notes or nurses notes?
Subject: Nurses' notes or nurse's notes or nurses notes?
I am so confused on this one. I have typed it several different ways over the years. Do I really need to put any apostrophe in there at all? Thanks!
Nurse's notes reviewed or nurses notes reviewed? nm
Subject: Nurse's notes reviewed or nurses notes reviewed? nm
x
op notes
Here is a list from my favorites. Hope they are a little bit helpful. I think they are all still good sites.
Op note sites:
http://www.mt-stuff.com/ent.html
http://mtdesk.com/gen.shtml
http://www.medical-library.org/journals2a/tubal_ligation.htm
http://www.mtdaily.com/samples.html
http://www.nezhat.com/oplap_abst.htm
http://www-personal.umich.edu/~aalin/vitalsigns/contentappendix/cntappsamplenotes.html
op notes
Subject: op notes
I have never encountered such a rule. I don't generally listen to where the dictators want their paragraphs, though. They usually put in way too many. I start a new paragraph after the prep and drape description and a I start a new paragraph for the closing of the wounds. I add new paragraphs when the surgeon is addressing a new area. That's just my style of transcribing. I'm not saying it's the right way to do it. It just makes sense to me and I would think it is easier to read and comprehend that way.
take notes!
Subject: take notes!
Whenever I have to spend a lot of time looking something up, I make sure to write it down. It's worth it.
I don't do op notes! LOL
Subject: I don't do op notes! LOL
thanks - i usually do ER notes so not familiar with that!
Subject: thanks - i usually do ER notes so not familiar with that!
Resources for OP notes?
Subject: Resources for OP notes?
Is there anyone here who does operative notes and gynecology notes who could give me some websites to use for resources? I am on an OB/GYN account and have operative notes. I have trouble sometimes with the specific surgical instrument names and would greatly appreciate any help. Thanks in advance.
Resources for OP notes?
Subject: Resources for OP notes?
My suggestion would be to purchase (if you do not already have)OB/GYN, equipment and surgical word books (Steadman's) my choice and you would be equipped to better perform your job.
OP notes resources
Subject: OP notes resources
I would do that but we are on a tight budget as we just bought a house and are getting in married in september.
Paragraphs in Op notes
Subject: Paragraphs in Op notes
I have noticed that when I transcribe an Op note as the dictator dictates it, starting a new paragraph as dictated...that QA always removes the spacing between the paragraphs.
Is there some rule in transcription that you don't break an op note into paragraphs? The client profile does not say anything about this.
SOAP notes
Subject: SOAP notes
Was wondering if there are any websites out there that gives sample reports for SOAP notes. Just trying to figure out which is the best way to do it with paragraphs between each heading or all scrunched together. Just want to see what is done more of. I realize it might depend on the clinic, dr, hospital, etc, but just want to get an idea.
Thanks Carla
Thanks so much! I'm taking notes!
Subject: Thanks so much! I'm taking notes!
SOAP notes
Subject: SOAP notes
transcribing for 7 1/2 week old child. Dictator states fontanels are flat, sound like "contrapendalence" are normal.
I have parascapular in my notes.
Subject: I have parascapular in my notes.
Think just nurses notes. IMO. nm
Subject: Think just nurses notes. IMO. nm
Nurse's notes..
Subject: Nurse's notes..
An apostrophe shows ownership. :-)
Does anyone know a good website for op-notes...
Hi, does anyone have any websites that are good for surgical words? I have limited books, try to use Int. for most everything. I use surg. instrument sites to look up tools, but not always successful or spend too much time looking through their quite extensive catalog. Thanks for your help...Suzy
Does anyone know a good website for op-notes...
Does anyone now a good website or two for surgical notes? I at times use a surgical instrument site but if I don't know how to spell something, I have to look through extensive catalog listings...or if I get a foreign accent and can't make out what he is saying, then I have big problems, so a site that has sample notes would be a big help too. Thanks for your help. Suzyq
Can you look at the doc's other notes and see how he words his/her followups? ...maybe something
Subject: Can you look at the doc's other notes and see how he words his/her followups? ...maybe something
s
thank you very much, I will write that in my future notes
Subject: thank you very much, I will write that in my future notes
Good luck to you then!! Op notes are a sm
Subject: Good luck to you then!! Op notes are a sm
whole nother mess!! Do you have these sites for equipment, latest things etc?
http://www.medcompare.com/
======================
Another good site:
http://www.surgical911.com/
No, I cannot confirm. I have some personal notes
Subject: No, I cannot confirm. I have some personal notes
that I make and had Segund in them.
LOL And I'm a nurses' notes kinda gal. N/M
Subject: LOL And I'm a nurses' notes kinda gal. N/M
Just so you (or anyone taking notes) know, it's Le Fort fracture, no e on the end. nm
Subject: Just so you (or anyone taking notes) know, it's Le Fort fracture, no e on the end. nm
x
always typed skeletonized in op notes over the years. sm
Subject: always typed skeletonized in op notes over the years. sm
The infundibulopelvic ligament was skeletonized by fenestrating the posterior broad ligament over the avascular window above the ureter, then tied with a ...
www.blackwell-synergy.com/links/doi/10.1046/j.1525-1438.2002.01038.x/full/ - Similar pages |
Through a window in the mesosalpinx the infundibulopelvic ligament is skeletonized and clipped. The anastomotic artery near the cornu is clipped, ...
pt.wkhealth.com/pt/re/ajog/fulltext.00000447-200003000-00002.htm - Similar pages |
[PDF]
File Format: PDF/Adobe Acrobat
skeletonized the anterior leaf of the broad ligament, the. posterior leaf is then skeletonized, ... angle to get to the infundibulopelvic ligament and a ...
www.ligasure.com/pdf/gyn/Linnovbisalp.pdf - Similar pages |
Glad you like the link. Very helpful in WC notes. nm
Subject: Glad you like the link. Very helpful in WC notes. nm
I have sticky notes everywhere with different stages, grades, etc. sm
Subject: I have sticky notes everywhere with different stages, grades, etc. sm
I think I used to think most stages were roman numerals and most grades were arabic but there are way too many exceptions so I try to figure out which one it is for each specific instance and then write it on my growing list. BOS says types are arabic, roman numerals, or capital letters depending on type referred to. I WISH there was a website with all of the different stages, grades, types, etc. listed. Does anyone know of such a thing??
Nursing notes no problems and feels
Subject: Nursing notes no problems and feels
Here is my working list for HIV drugs most often dictated in notes
Subject: Here is my working list for HIV drugs most often dictated in notes
Abacavir
Amprenavir
Atovaquone
AZT
Combivir
Delaviridone
Didanosine
3TD
3TC
d4T
Efavirenz
Indinavir
Kaletra
Lamivudine
Nelfinavir
Nevirapine
Ritonavir
Stavudine
Sustiva
Tipranavir
Trizivir
Viread
Zalcitabine
Zidovudine
This is blanked in his past notes, too. Gotta send it. Thx anyway. nm
Subject: This is blanked in his past notes, too. Gotta send it. Thx anyway. nm
s
NEW to OP notes--inguinal hernia repair--4 questions
Subject: NEW to OP notes--inguinal hernia repair--4 questions
1. Local was infiltrated under the external oblique and then the external oblique was opened and the (?trex-i-vus?) fibers through the external ring.
2. This was brought to lie with the mesh overlying the pubic tubercle a good 2cm. This was anchored in the pubic tubercle with a (?sounds like no no-ah-fill or Novafill?)
3. verbatim: The patient was placed in supine position on the operating table (?sounds like minute?) given IV sedation his groin was prepped with Betadine and (? sounds like eye-sid--doesn't sound like iced?) with sterile towels and a transfer sheet.
4. (?En-er-up-tids?) were placed in the Scarpa's fascia and the skin was closed with staples.
Thanks to those who helped me this morning!
Maybe 'rage'? Can you check other notes to see what's commonly evaluated by this doc? nm
Subject: Maybe 'rage'? Can you check other notes to see what's commonly evaluated by this doc? nm
s
I have SennaLax-S in my notes but I don't remember where I found that to verify it for you NM
Subject: I have SennaLax-S in my notes but I don't remember where I found that to verify it for you NM
Nevermind, found it in my notes. Opus is correct. nm
Subject: Nevermind, found it in my notes. Opus is correct. nm
ss
In the olden days at the hospital the for said nurses notes. nm
Subject: In the olden days at the hospital the for said nurses notes. nm
Are you reading this off of doc notes or is he/she giving you these single letters in dictation? nm
Subject: Are you reading this off of doc notes or is he/she giving you these single letters in dictation? nm
s
Can you see samples of how the other MTs handle it? Are these SOAP notes? Can you number the probs
Subject: Can you see samples of how the other MTs handle it? Are these SOAP notes? Can you number the probs
s
pt. came in with appendicitis, but in postop notes, dictator keeps saying left epi/appe?
Subject: pt. came in with appendicitis, but in postop notes, dictator keeps saying left epi/appe?
Any one know sounds like "paint rainy clips" in surgery. Don't do a lot OP notes so not fa
Subject: Any one know sounds like "paint rainy clips" in surgery. Don't do a lot OP notes so not familiar
nm
Oh got it, yes there is a Compass sheet used for therapeutic notes in medical management.
Subject: Oh got it, yes there is a Compass sheet used for therapeutic notes in medical management.
You are welcome. I have learned all sorts of strange stuff typing ED notes. nm
Subject: You are welcome. I have learned all sorts of strange stuff typing ED notes. nm
nm
s/l Bez or all in change
Subject: s/l Bez or all in change
shows the patient in sinus mechanism 66 beats per minute, normal intervals, normal axis. Voltage criteria for LVH and s/l Bezoiorall is change in comparison to prior EKG dated
Thanks so much to both of you. I will change to 6, 90, and -1. nm
Subject: Thanks so much to both of you. I will change to 6, 90, and -1. nm
I change that to:
Subject: I change that to:
I change elicitable (which to my knowledge has never been a "real word" to "able to be elicited." My doctor dictator thanked me for this once (I was suprised that he noticed). I checked this out with several transcripitionists that I have worked with who have lots of experience and are CMTs and they also edit this word to "able to be elicited."
I'm not CMT and I change that the same way...nm
Subject: I'm not CMT and I change that the same way...nm
 
cc to mL - do you change cc to mL
Subject: cc to mL - do you change cc to mL
according to AAMT or do you type cc
Thanks
Would you change this...
Would you change CT head to say head CT? The doctor says CT head.
Thanx
VR change
Subject: VR change
He should point it out to his supervisor because it is wrong. I don't care what QA says unless they can show me a resource where they got their information and it checks out. I would also point out to the client this fact. If they don't want to have their transcription correct and concise then I don't want their work. Right is right, wrong is wrong. I am really strong on this especially since the "new AAMT" has made all their "changes" and believe their BOS is the bible. It is not. Many of their "rules" are correct. Many of the are not. Research some of their changes and you will see just how over the top they have gone (it seems to be a control issue and they WILL cram it down your throat). I say that we all research on our own and go to reliable trusted sources that have been proven over time to be correct. The "New AAMT" definitely has not proven itself over time and incidentally they are not there for Americans anymore, they are there for the "overseas community." Humbug on them! Anyone know who could take the place of AAMT for American transcriptionits? After all, we are all Americans here and the language is English.
I would change it to this
Subject: I would change it to this
patients blood pressure readings at home daily have been 90 percent plus. Would leave as is or change........looks wrong.
Patient's daily at home blood pressure readings have been 90%+.
they can change...
Subject: they can change...
depends on what the MD hears on auscultation; that being said, it usually is 3/6, 2-3/6...etc... six is the prime as there are standard 6 heart sounds and the first number being how many of the 6 they hear.
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