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I did type 23 hour observation. Really. See ref again.

Posted By: Txczech on 2007-03-28
In Reply to: Word Help - MTTX

Subject: I did type 23 hour observation. Really. See ref again.

Coding and Documentation - March 2001 Family Practice Management



Q: If I admit a patient for "23-hour observation" and then it is necessary to convert that to a regular admission at the 24-hour mark, what code should I ...
www.aafp.org/fpm/20010300/coding.html - 22k - Cached - Similar pages



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Found hits for ൟ hour observation". sm
Subject: Found hits for ൟ hour observation". sm

May be saying 23 hour observation before a CXR etc? Just a thought.


 


 


Coding and Documentation - March 2001 Family Practice Management






Q: If I admit a patient for "23-hour observation" and then it is necessary to convert that to a regular admission at the 24-hour mark, what code should I ...
www.aafp.org/fpm/20010300/coding.html - 22k - Cached - Similar pages


 


 


I would type q. hour of sleep or at bedtime, q.h.s. is on the dangerous abbrevation list.
Subject: I would type q. hour of sleep or at bedtime, q.h.s. is on the dangerous abbrevation list.

xx
just a quick observation..sm
Subject: just a quick observation..sm

In reading the rest of this note, I have a feeling it is not *hallucis*, but since the rest of the note indicates hallux and foot care, I have a feeling he is saying halluxes, if that is even a word, as in plural hallux. It is a podiatry word, for sure. at least in my opinion. There are many hallux procedures, one of which is Youngwich procedure.
crazy observation here, but could he be describing...sm
Subject: crazy observation here, but could he be describing...sm

the sound of the puffs being administered, instead of staying 1 "puff" b.i.d., he's saying something that sounds like the med being administered?  I know that sounds dumb, but that's what comes to my mind.
1/2-hour or one-half hour......
Subject: 1/2-hour or one-half hour......

Help....my brain is not working today!


 


Yale observation score link (sm)
Subject: Yale observation score link (sm)

http://www.fpnotebook.com/ID50.htm
1/2-hour.
Subject: 1/2-hour.

nm
that should say 24-hour
Subject: that should say 24-hour

/
i would think it says 24 hour UA
Subject: i would think it says 24 hour UA

...
h. for hour
Subject: h. for hour

I would say follow the rules of the company on using q. 4 h. or not. I would also ask tech support or training (if you have it) about the capital letter after a period.
q. hour of sleep
Subject: q. hour of sleep

How do you type q. hour of sleep?
q. hour of sleep
Subject: q. hour of sleep

I e-mailed AAMT with this same question about a month ago.  Their response to me was as follows:


"He may be dictating "hour of sleep" because he expects you to use the abbreviation h.s. However, this particular abbreviation is on the Dangerous Abbreviations List, and we are encouraged to transcribe this as either "nightly" or "at bedtime." If the dictator questions you about this, you can show him the appendix in your Book of Style or refer him to the Dangerous Abbreviations List under Patient Safety Goals on the JCAHO web site (www.jcaho.org)."


second one was clock hour
Subject: second one was clock hour


Is it a baby or someone in CHF? We used to run IVs at 100 or 125 cc per hour in the hpl. nm
Subject: Is it a baby or someone in CHF? We used to run IVs at 100 or 125 cc per hour in the hpl. nm

s
Regarding letter h (hour) per BOS...please sm

Letter h. (with a period) is the abbreviation for the Latin word hora, meaning hour.


q.6 h. (every 6 hours)


In instructions for medications, Latin abbreviations may be coupled with English terms, such as hour. These may be transcribed as dictated or the English translated to Latin.


every 4 hours or q.4 hours or q.4 h or q.4 h Copyright (c) 2002 American Association for Medical Transcription.  So does this mean we can do the q.4 h without the period at the end of h, because I am constantly having to remove capital letters from words following the h with a period.  Thanks.


THANK YOU I'm glad someone is up and able to help at this hour! I think that might be it, ,but I
Subject: THANK YOU I'm glad someone is up and able to help at this hour! I think that might be it, ,but I can't convince myself. It's repeated several times and each time is a little different. nm

x
Duragesic 12 mcg q. hour, q. 3 d. #10
Is q. hour (or q.h.) correct. Wouldn't that be "every hour"?
10 KCL per kilo per hour
Subject: 10 KCL per kilo per hour

10 mEq/kg/hr


Row checks every hour?
Subject: Row checks every hour?

This is for a patient brought into emergency after a roll over motor vehicle accident. He has a subdural hematoma and the RN states he was given what sounds like "row checks" every hour.  I am not familiar with ER procedures- can anyone interpret this for me? 
24-hour urine test... sm
Subject: 24-hour urine test... sm

Possible islet tumor in the head of the pancreas. 


Her 24-hour urine for ***BMA*** was normal. Her 24-hour urine for 5HIAA was normal. Her 24-hour urine for cortisol was normal. Her 24-hour urine for normetanephrine and metanephrine was essentially normal.


I cannot verify this or find anything close to this.  Can anyone help??


s/l ROTH HOUR TA SPOTS
Subject: s/l ROTH HOUR TA SPOTS

She had AV nicking on funduscopic exam, no hemorrhages or exudates or s/l Roth hour TA spots.


 


Later on in the report says...


She had no splinter hemorrhages or s/l J way nodes.


 


Thank you Deborah


ൠ-hour intake" maybe? NM
Subject: ൠ-hour intake" maybe? NM


Pt was given s/l Clinomix 30 mL per hour intravenous. TIA
Subject: Pt was given s/l Clinomix 30 mL per hour intravenous. TIA


Have one for me I have another hour... Happy Thanksgiving !
Subject: Have one for me I have another hour... Happy Thanksgiving !


2-hour s/l p.c. or PC glucose. Which is correct? nm
Subject: 2-hour s/l p.c. or PC glucose. Which is correct? nm


how to abbreviate miles per hour
What is the correct way to abbreviate miles per hour in a medical report? Is mph ok?


s/l tube feeding 85 cc of Glucerna per hour
Subject: s/l tube feeding 85 cc of Glucerna per hour

Would 85 cc be right?


Then says s/l "20 cc" fluid flushing every shift.


TIA!


pt on Humalog with a s/l Bazorate? of 1.6 units per hour
Subject: pt on Humalog with a s/l Bazorate? of 1.6 units per hour


Just a guess - final or 5-hour (I believe it is an adjective)
Subject: Just a guess - final or 5-hour (I believe it is an adjective)


q.h.s. should be at bedtime or at hour of sleep due to clarity. Actually I have never seen q. hs bef
Subject: q.h.s. should be at bedtime or at hour of sleep due to clarity. Actually I have never seen q. hs before.


IUP at 38 weeks, s/l SHROM? times 1 hour
Subject: IUP at 38 weeks, s/l SHROM? times 1 hour


I was taught that q. should not stand alone, therefore, if it was q. hour I would transcribe it as e
Subject: I was taught that q. should not stand alone, therefore, if it was q. hour I would transcribe it as every hour


The QA people I know make at least 18.00 an hour (east coast)
Subject: The QA people I know make at least 18.00 an hour (east coast)


Med help please s/l Basorate 0.85 units per hour--just listed in med list.
Subject: Med help please s/l Basorate 0.85 units per hour--just listed in med list.


normal saline with 20 k/liter over approximately a 2-3 hour period.
Subject: normal saline with 20 k/liter over approximately a 2-3 hour period.

normal saline with 20 k/liter over approximately a 2-3 hour period.


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
The actual Latin conversion for q.h.s. is every hour of sleep, but I go by the client profile for th
Subject: The actual Latin conversion for q.h.s. is every hour of sleep, but I go by the client profile for the facility that I transcribe, some want at bedtime, some do not clarify, some want at hour of sleep.


Sorry guys, but I have puti n an 11 hour day with bilateral ear infections, so time to hit the deck.
Subject: Sorry guys, but I have puti n an 11 hour day with bilateral ear infections, so time to hit the deck. Have a good night.


cardiac catheterization, s/l After balloon valvuloplasty, on pull back, there was a 32 hour gradient
Subject: cardiac catheterization, s/l After balloon valvuloplasty, on pull back, there was a 32 hour gradient

is 32 hour gradient correct???  Thanks...
48-hour pH test completed and extensive *physiatry* to view the findings which demonstrated
Subject: 48-hour pH test completed and extensive *physiatry* to view the findings which demonstrated

She states that she is unable to eat, continues to lose weight, and is having bouts of vomiting.  She did have her 48-hour pH test completed and extensive *physiatry* to view the findings which demonstrated that on the first night when she had vomited after her procedure, there were some episodes of breakthrough acid; however, the following day when she was tolerating a diet and had her AcipHex, her pH was well controlled, above a pH of 4, essentially the entire time.  Therefore, I discussed with the patient that her chest burning does not appear to be correlated with breakthrough acid of any significant degree and suggests the possibility that a lot of her chest pain and burning may be related to her anxiety and depression.
with time are you supposed to put the word hour after the time, i.e. 1600 hours
Subject: with time are you supposed to put the word hour after the time, i.e. 1600 hours

nm
Duragesic patch dose is 12 mcg per hour, changed every 3 days: 12 mcg/hr every 3 days, #10
Subject: Duragesic patch dose is 12 mcg per hour, changed every 3 days: 12 mcg/hr every 3 days, #10

x
same here. Type out numbers at beginning of sentences. Otherwise type numeral if in sentence itself.
Subject: same here. Type out numbers at beginning of sentences. Otherwise type numeral if in sentence itself.

nm
Patient with type 2 diabetes prescribed a s/l glutisone type drug. nm
Subject: Patient with type 2 diabetes prescribed a s/l glutisone type drug. nm


which is preferred ~ diabetes mellitus type II or type 2?
Subject: which is preferred ~ diabetes mellitus type II or type 2?


I get confused, how do you type out grade, class, type SM
Subject: I get confused, how do you type out grade, class, type SM

I forget which ones  use Roman and which do not.  TIA


We will do neurochecks q 1 hour for 8 hours and then 2 q hours X 4.
Subject: We will do neurochecks q 1 hour for 8 hours and then 2 q hours X 4.


After a half an hour of searching and searching
Subject: After a half an hour of searching and searching

I finally found it. He was saying endocrine neoplasia. Just thought I'd let you all know.
When doctor says tib-fib, do you type it like that or do you type tibiofibular? Thanks
.
Siewart type I or Siewert type I
Subject: Siewart type I or Siewert type I

When I google it, I'm finding both.  Cannot locate it in a Stedman's book.  Doctor spells with "a" but you can't always go by the spellings!
How do I type this particular type of dialysis bath? sm
Subject: How do I type this particular type of dialysis bath? sm

Doc is an ESL and unclear, but it s/l he is saying "...using a 3 K 21/2 bath." I have never had this in a report and after googling, am still as clueless as I was. I cannot find it in AAMT, either. Any help would be appreciated. Thank you!