I have a couple of docs that do this. sm
Posted By: Frustrated too! on 2009-01-09
In Reply to: Lab Help - Abby
Subject: I have a couple of docs that do this. sm
The terms sound similar anyway, and if they say them a little too fast, or there's a flaw in the sound, these words sound exactly the same.
But sometimes there's a clue in what's being tested, blood or urine, and/or the diagnosis.
Also, if you can slow the sound down a little, sometimes you can hear a slight difference, just enough to know it's one or the other.
If that doesn't help, the best thing would be to send on to QA. If they can't figure it out, the docs may become tired of blanks and learn to enunciate more clearly. How difficult could that be!
Sorry I can't be of more help, but maybe someone else has a foolproof way to tell.
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I have a couple of docs that do this. sm
Subject: I have a couple of docs that do this. sm
The terms sound similar anyway, and if they say them a little too fast, or there's a flaw in the sound, these words sound exactly the same.
Is there a clue in the dx?
If you can slow the sound down a little, sometimes you can hear a slight difference, just enough to know it's one or the other.
If that doesn't help, the best thing would be to send on to QA. If they can't figure it out, the docs may become tired of blanks and learn to enunciate more clearly. How difficult could that be!
Sorry I can't be of more help, but maybe someone else has a foolproof way to tell.
There are a couple...sm
Subject: There are a couple...sm
Here is a great site with a couple of choices that sound like your term.
http://www.suffolkobgyn.com/medicalTerms#G
a couple T's
Subject: a couple T's
tap water enema
theophylline olmamine enema
tranexamic acid enema
turpentine enema
A couple more....
Subject: A couple more....
he went on to have an aortic valve replacement with a "number tommy five" bioprosthetic valve as well as bypass "sinus tree" vessels
pseudo normal LV filling pressure with "chronkomittent" abnormal relaxation
Patient is New York Heart Association class III in the setting of ischemic cardiomyopathy and "he feels" compensated
beta blockers, carvedilol "a target dose", "aldolsol" inhibitor
THANKS!
I too would like to know a couple of shortcuts..
Subject: I too would like to know a couple of shortcuts..
such as, I end each letter from my doc with "Thank you for the referral of the patient." Sincerely, John R. Brown, MD JEB/trh. I know there must be a way to store this so that all I have to do is strike 1 key to end my letters, but I don't knave a clue how to do this. Anyone have any suggetstions? Thanks
Couple of lab questions... sm
Subject: Couple of lab questions... sm
Can't catch what Mr. Mush-mouth is saying.
Postoperative serial white blood cell count demonstrated a stable white blood cell count at 11,900. s/l *hemansa* hemoglobin stable at 28.9 and 9.4.
a couple of thoughts
Subject: a couple of thoughts
First to address the issue of subcu - Joint Commission created a list several years ago that deals with this wording - and JC trumps BOS. From Joint Commissions List of Dangerous Abbreviations:
Abbreviation: S.C. or S.Q. (for subcutaneous)
Potential Problem: Mistaken as SL for sublingual, or "5 every"
Preferred Term: Write "Sub-Q", "subQ", or "subcutaneously"
As far as what the man was trying to express to you was his opinion that truncated words (partial words used to express a complete word) should be avoided. Trach is not a word. Trachea, tracheostomy, etc., are words. Alk is not a word. Alkaline is a word. There are also lab and other words that are commonly acceptable in their abbreviated form, such as INR, CPAP, MRI, etc.
There are acceptable abbreviations of certain words that are commonplace. For example, lab is widely accepted to represent laboratory. Exam is acceptable to represent examination. HIV is another example.
If you understand the difference between the use of an abbreviation and avoiding the use of truncated words, your work will reflect a much clearer intent of the dictation.
Your company needs to decide which side of the fence it wants to sit on, and it appears there may be some changes in your QA future. If this man is in charge of QA and you want to continue working there, you might want to begin taking note of what he is saying.
a couple of things......SM
Subject: a couple of things......SM
Jehovah's Witness
myoclonic gammopathy? not myoclinic
possibly *gammopathy*
*h* in Jehovah's Witness
couple of possibilities (sm)
Subject: couple of possibilities (sm)
If you're sure you're hearing "radio" that could be a "short-speak" way of saying radiograph.
Another possibility is RDI (respiratory disturbance index).
Have a couple of questions, please sm
Subject: Have a couple of questions, please sm
Sorry, filling in for somebody and this doctor is really fast -
1. Patient takes a s/l plepharde of medications.
2. Patient still has constipation despite taking s/l Cerafac.
Thanks!
There are a couple of possibilities. Context?
Subject: There are a couple of possibilities. Context?
Here are a couple of links for you to send them....
Subject: Here are a couple of links for you to send them....
http://72.14.253.104/search?q=cache:_yrLOF4eEkIJ:emcrit.org/pdf/Wound%2520Care%2520Syllabi.pdf+XAP+topical+pediatric&hl=en&ct=clnk&cd=13&gl=us (at bottom of page 8) Hope this helps...When the doc spelled it for me, it was for a laceration repair on a kid. But, if it's a dental block in the ER, they might be using ZAP for topical in the mouth. Was something that was really confusing for me at the time, which is why I tried to get some info on it.
Can we have a couple of lines from the report
Subject: Can we have a couple of lines from the report
so we'll know where he is?
New to ortho and have a couple words.
Subject: New to ortho and have a couple words.
s/l *jo-lie-tandis* pain with hyperflexion. (knee)
Negative s/l *feralmis* test. (wrist)
TIA!
Have heard it used a couple of times
Subject: Have heard it used a couple of times
Just another way to say serial cardiac enzymes, I believe
If he already gave you a couple, then it would be 'all other...' nm
Subject: If he already gave you a couple, then it would be 'all other...' nm
s
Thank You! That's it. He always swallows the first couple of letters when I need them the most.
Subject: Thank You! That's it. He always swallows the first couple of letters when I need them the most.
.
Can't understand a couple of words
Subject: Can't understand a couple of words
If you're transcribing a report about someone with sinusitis, and the doctor says the ___ are red and swollen (and it doesn't sound like nostrils or nares or membranes) what could it be? And in the PLAN if he says ___ fluids, rest, and follow up within 7 to 10 days....what could he be saying. It almost sounds like "Push fluids." Can anyone help? Thanks!
Depends on a couple of things
Subject: Depends on a couple of things
The first point would be the hospital's desires. They may or may not want abbreviations spelled out in a report. Also, usually if it's in a diagnosis somewhere, it almost always has to be spelled out, as most hospitals abide by the joint commission rule of no abbreviations. In a regular physical exam somewhere in the text of the report, most hospitals, clinics, etc., seem to want whatever abbreviations the doc may use, so in that case you would just leave it as it is (although this may differ in correspondence as some places prefer a more formal policy of no abbreviations in letters, so check account specifics).
couple of web sites in case you
Subject: couple of web sites in case you
can use them:
revolutionhealth.com/search
M.D. Anderson Cancer Institute, Houston
pathology.washington
bloodjournal.org
Thanks, she did it with a couple others, so that makes sense
Subject: Thanks, she did it with a couple others, so that makes sense
A couple questions relating to pancreas
Subject: A couple questions relating to pancreas
This is a patient with advanced pancreatic cancer. Here's the part I'm having trouble with. He was admitted to the hospital. "The patient did undergo attempts at [s/l ESRT or "e ester tee"?]. However, the tumor was protruding through the duodenum [s/l ambule] and common bile duct cannot be cannulated. He was determined to be unresectable and underwent a choledochojejunostomy, gastrojejunostomy, and enteroenterostomy for diversion." Whew! Any ideas?
Pulling my hair out - just a couple questions
Subject: Pulling my hair out - just a couple questions
This study is a right ilia-femoral ultrasound.
Is it ilia-femoral or iliac-femoral, and what about the hyphen?
ALSO......
I cannot figure out what he is saying here:
PROCEDURE REPORT: The abdominal aorta and right ilia-femoral (see above..) systems were S/L: insinated or instinated with a Doppler ultrasound transducer.
Thanks for any help!!
A couple questions regarding Cardiology/Hematology
Subject: A couple questions regarding Cardiology/Hematology
He does have some mild jugular venous distention (JVD). He does have a slightly positive patojugular reflex.
He does have a grade 1-2/6 murmur load on the lower left sternal border and apex. The lungs: He continues to have a few fine basaloreals on the posterior lower lobe. The abdomen is somewhat softer today, it is rounded.
A couple of grammar rules are at play here
Subject: A couple of grammar rules are at play here
First of all, both got and gotten are correct forms of the verb get. However, got is a past tense or past participle depending on whether or not the word "has" or "have" is used in front of it. Gotten, however, is past participle and should be used with the word "has" or "have" in front of it.
It has gotten increasingly larger - okay. It gotten increasingly larger - not okay. It got increasingly larger - okay. It has got increasingly larger - okay.
So if your doc says it anyway but "It gotten increasingly larger", he is correct. It's simply a matter of preference. Brits don't generally use the word "gotten", and therefore, a lot of people think it is not a legitimate word, but it is.
Need help with the MR angiogram in mesage, couple of questions and maybe more :) sm
Subject: Need help with the MR angiogram in mesage, couple of questions and maybe more :) sm
the MR angiogram of the posterior circulation intracranially showed a variant circulation with prominent bilateral “fetal” origin of the PCAs and distal basilar and "P1 segmental" hypoplastic were absent.
A couple of questions regarding Cardiology/Hematology
Subject: A couple of questions regarding Cardiology/Hematology
Hi, sure hope this helps. I had that recently. It is he has a slight hepatojuglar reflux sometimes referred to as reflex but more correctly it is reflux. Also it is "He continues to have a few basilar rales in the posterior lobe."
Does he state 20 the first couple of days or does he give any time along with that? SM
Subject: Does he state 20 the first couple of days or does he give any time along with that? SM
If not, I would just type as dictated and maybe put quotations around it if you are certain of what he is saying. HTH
SKIN: She has a couple of dermal nevi, nothing that looks suspicious. A few MILEAM on the nose. nm
Subject: SKIN: She has a couple of dermal nevi, nothing that looks suspicious. A few MILEAM on the nose. nm
gram-negative, lactose-negative rods is correct. I found a couple of interesting websites SM
Subject: gram-negative, lactose-negative rods is correct. I found a couple of interesting websites SM
after doing a google search for gram-negative, lactose-negative rods. Basically testing organisms to see if they ferment lactose (positive) or not (negative).
Also, just FYI, gram-negative is not capitalized.
Probably too late, I'm sure. Better late than never, I guess. 
Yep, it's okay. Docs say that often. nm
Subject: Yep, it's okay. Docs say that often. nm
x
Thanks...sometimes I think these docs should...
Subject: Thanks...sometimes I think these docs should...
type themselves for once and listen to some of the things they say. I bet they would think twice after that...:-)
Some docs
Subject: Some docs
actually dictate ABGs in this manner. They say a number then slash then another number then slash, etc. That is how they want it transcribed. Just make sure your numbers are correct and you are set to go!
should say *my* docs
Subject: should say *my* docs
like the docs who are always ...
Subject: like the docs who are always ...
... putting "metatarsal" in the hand dictations. Plantar may be technically okay, but it seems like if he were more careful he would say palmar.
Our docs
Subject: Our docs
usually say normocephalic.
I have docs that use it
Subject: I have docs that use it
but my account is not crazy weird picky, either. I haven't heard of it being unacceptable. If it's worth your time, I'd question QA about it and ask her why she changed it.
I have docs
Subject: I have docs
who add extra letters to lots of words, if it make them easier to pronounce. Kind of weird, but it happens.
Docs
Subject: Docs
make up lots of words...they make lots of mistakes (ergo malpractice insurance)...they even misspell lots of words. If we have to deal with their ineptness, they can deal with blanks. JMHO. :-)
With some docs..
Subject: With some docs..
that wouldn't be a stretch at all but a very good guess. :-)
It's not the docs I'm concerned about, or QA, when it comes to my...
Subject: It's not the docs I'm concerned about, or QA, when it comes to my...
work as an MT,
You don't add in mg or mcg, etc. unless it's dictated. The docs know
Subject: You don't add in mg or mcg, etc. unless it's dictated. The docs know
s
that's how my derm docs like it - sm
Subject: that's how my derm docs like it - sm
same with T zone.
ONLY if your QA, account, or docs want it to be so. Not everyone
Subject: ONLY if your QA, account, or docs want it to be so. Not everyone
s
The docs are correct. (nm)
Subject: The docs are correct. (nm)
.
the docs are incorrect
Subject: the docs are incorrect
there must be ownership to use an apostrophe. The word Smith does not show ownership to anything.
If the sentance read Dr. Smith's patient, then yes the apostrophe is used.
that's the section m docs usually put it in.
Subject: that's the section m docs usually put it in.
No, it is not. Docs do not always spell
Subject: No, it is not. Docs do not always spell
x
Some of my docs do list..sm
Subject: Some of my docs do list..sm
each artery's findings separately and I number them along the left under each other. Just use your common sense so you end up with a clear report. Good luck. I remember when I first started doing caths and it wasn't easy.
know how the docs are... making up as they go sm
Subject: know how the docs are... making up as they go sm
They are two separate ligaments but he is probably putting them together.
Most docs say "hypertrophy" when they
Subject: Most docs say "hypertrophy" when they
say it out instead of abbreviating. But, when in doubt, use the abbreviation, even if in diagnosis.
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