I know...lots sounded very weird. :) Thanks. NM
Posted By: Chickadee on 2005-10-01
In Reply to: LOPS - karibari
Subject: I know...lots sounded very weird. :) Thanks. NM
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Lots of Detail for Lots of Help!
Subject: Lots of Detail for Lots of Help!
Okay, I'm transcribing a SOAP note and this word that I'm trying to figure out is under the ASSESSMENT AND PLAN part. She says the word three times and I am now thinking she is saying something like "number next or number next is." What do you think?
(Normonaxis) Anemia may be caused from a recent epistaxis. He will start an iron pill daily over the counter called Fergon. Next visit we will check a hemoglobin, iron studies. (Normonax) He was in for right shoulder pain in the past. This was resolved. (Normonax) Recent qualm was treated with doxycycline.
Also, I was told to transcribe this using a straight SOAP format, but the doctor dictates things like "Review of Systems" and "Exam." I didn't think those headings or subheadings were in a SOAP format. She never dictates "Subjective" or "Objective," only "Assessment And Plan" as one heading towards the end of the report. Any advice?
s/l sounded ? sm
Subject: s/l sounded ? sm
The uterus ____ to 8 cm. Under sterile conditions using a Novak curette two samplings were done for a small amount of endometrial tissue.
Thanks in advance. This dictator loves to talk but is not very clear.
Okay, thank you-Sounded really
Subject: Okay, thank you-Sounded really
high for BNP, but I was pretty sure BMP had mroe than 1 value! Thanks again.
It sounded like
Subject: It sounded like
At first, it sounded like Tissue-Link but then relistened and it sounded more like ending with an ''n'' like Tissuleen (pretty bad sound quality though)
Thanks for the help.
sounded
Subject: sounded
Thanks! That is what it sounded like she was saying!!
Subject: Thanks! That is what it sounded like she was saying!!
too weird! sm
Subject: too weird! sm
The very next report I got after this one, from a different doc, different place, he says "microfracture" which I think must be what the first one was talking about (she loves the abbreviations). So strange that I've never heard this term, but I get it in 2 consecutive reports!
Yes, weird indeed. When he said it
Subject: Yes, weird indeed. When he said it
I said WHAT?? He is very, very clear too. I will send it in with a blank and see what QA says. Thanks for your help.
That is weird!
Subject: That is weird!
If it's not a verbatim account, I'd use "medications" and "detoxification". I'd think they'd have a hard time picking a fight with those! (Plus, it's more characters!)
Me, too. Looks weird.
Subject: Me, too. Looks weird.
Too weird
Subject: Too weird
my editor and I were just discussing this yesterday. I was always taught to put what is dictated, but she said to always expand it - - now, I am confused.
That is weird
Subject: That is weird
because Desonide is not to be used in the eyes.
Thanks SO much..it sounded so familiar sm
Subject: Thanks SO much..it sounded so familiar sm
and that has to be it. She does have a history of depression among other things.
THANKS!
The uterus was sounded to
Subject: The uterus was sounded to
is what they usually say. You heard right.
he spells out what sounded like R E M P
Subject: he spells out what sounded like R E M P
That's it! "And" sounded like "N". Thank you very much!
Subject: That's it! "And" sounded like "N". Thank you very much!
Yes, a new one on me too. Sounded very strange. nm
Subject: Yes, a new one on me too. Sounded very strange. nm
ss
No, it sounded like curlets? Thanks though.
Subject: No, it sounded like curlets? Thanks though.
It really sounded like it started with a "P"
Subject: It really sounded like it started with a "P"
x
Thank you, that is it, B and V sounded alike nm
Subject: Thank you, that is it, B and V sounded alike nm
nm
honestly no... just sounded like it might be what he/she was saying.
Subject: honestly no... just sounded like it might be what he/she was saying.
because it sounded very much likely share
Subject: because it sounded very much likely share
thanks
Perhaps a 'CCAM' (sounded out...
Subject: Perhaps a 'CCAM' (sounded out...
as 'See-Cam') check google for CCAM...
Yes, same here. Looks like it might have stopped though. Weird!
Subject: Yes, same here. Looks like it might have stopped though. Weird!
.
Thanks... It's not in there. Must be a weird one, I guess!
Subject: Thanks... It's not in there. Must be a weird one, I guess!
nm
Weird question?
Subject: Weird question?
I have a personal question to ask and I don't know if this is a problem or not. For the past few weeks my left foot will occasionally get so cold I can't stand it and the rest of my body is fine. This only seems to happen when I am typing. My right foot is my pedal foot. My mother had surgery to remove a blood clot from her arm (she almost lost the arm) many years ago. Is this something that I should be concerned about? Does anyone else ever have this problem?
weird question here :)
Subject: weird question here :)
I am unsure if I have the spelling correct for this word! It is talking about the patient having pink eye. He says he has to clear it out because it is crusty and pusy. I do not kno of any other way to spell pus other thank this. It just looks different. Please let me know. Thanks.
it looks weird to me too...I always change it to...
Subject: it looks weird to me too...I always change it to...
it's not necessarily correct - but I think about pussy cats and so the *eye is crusty and has pus* is what I'd put. 
Weird!! we BOTH started it with DU....
Subject: Weird!! we BOTH started it with DU....
Weird phrase
Just had a doc say: Lungs clear to IPPA. It's a first for me, but Google had hits for it, so I'm sure it's common. But how odd to say during the physical exam that lungs are clear to INSPECTION, palpation, percussion and auscultation.
I think of looking carefully when I hear inspection. So it sounds like he somehow took a peak at her lungs. Was he using a bronchoscope for this physical exam (no way - because he'd have documented that carefully so he could charge for it, LOL).
Now I'm off to check and see what OneLook says about inspection. Oy.
OK, this sounds weird
Subject: OK, this sounds weird
Patient is scheduled for an Afro? due to critical limb ischemia
Hey birdlady - what are those weird
Subject: Hey birdlady - what are those weird
Thanks for the laughs. I kept trying to hear 34 weeks, but it was pretty clear he was saying 24 weeks. I ended up flagging it as a discrepancy and sent it in to QA for them to figure out. Thanks for trying, though!
That should be Ƌ.1'...don't know where that weird symbol came from...nm
Subject: That should be Ƌ.1'...don't know where that weird symbol came from...nm
*
Just checking. The dictation sounded like it sm
Subject: Just checking. The dictation sounded like it sm
was coming from the same dictator. Have a good day!!! :)
I was thinking it was cellulitis, but it sounded like an M in there
Subject: I was thinking it was cellulitis, but it sounded like an M in there
x
blank also sounded like it could be crippling
Subject: blank also sounded like it could be crippling
definitely sounded like "shaw". Going to flag it. thanks. nm
Subject: definitely sounded like "shaw". Going to flag it. thanks. nm
x
That's it! Thanks... sounded like a strong V sound
Subject: That's it! Thanks... sounded like a strong V sound
thats it.sounded like she was saying shy-cari II. you are absolutely right. thank u
Subject: thats it.sounded like she was saying shy-cari II. you are absolutely right. thank u
thanks so much! it sounded so strange to me - thanks for verifying :)
Subject: thanks so much! it sounded so strange to me - thanks for verifying :)
did google, but really sounded like there was an "l" at the end. thanks ladies.
Subject: did google, but really sounded like there was an "l" at the end. thanks ladies.
Thank you, accent, sounded like "vasting" ha! ha!
Subject: Thank you, accent, sounded like "vasting" ha! ha!
xx
Sheesh - that's exactly what he was saying, but the "a-d" sounded like "eee-dee". n
Subject: Sheesh - that's exactly what he was saying, but the "a-d" sounded like "eee-dee". nm
nm
Thanks. That has to be it. Never heard of it and sounded like all one word.(nm)
Subject: Thanks. That has to be it. Never heard of it and sounded like all one word.(nm)
reading that, it sounded rude. sm
Subject: reading that, it sounded rude. sm
I did not mean it that way. Again, just a pet peeve of mine.
Yes...looks weird, but verified in my Stedman's. NT
Subject: Yes...looks weird, but verified in my Stedman's. NT
d
Kind of a weird way of putting it but SM
Subject: Kind of a weird way of putting it but SM
To amass something is to collect it or accumulate it. I have amassed a large collection of reference books over the years.
Too weird...when I opened this first time....sm
Subject: Too weird...when I opened this first time....sm
I only had the "subject" sentence and not the last 2 sentences. Am I crazy and somehow I just didn't see them...or is that possible somehow???
Consult - I think you are right! It just sounds weird....TU
Subject: Consult - I think you are right! It just sounds weird....TU
I promise, I'm not crazy...But this is a weird one! SM
Subject: I promise, I'm not crazy...But this is a weird one! SM
I know, it sounds crazy... This is a new urology account for me, and the doc is REPEATEDLY saying the following, taken directly from the notes:
(Problem of interstitial cystitis and pelvic pain) -- 'She did not use the Valium vaginal suppositories. She had days when she felt quite well....'
(Problem of IC again) -- 'Prescribed Valium 10 mg vaginal suppositories...'
(Problem IC and pelvic floor tension myalgia) -- She stopped her Valium vaginal suppositories, which she states are at a dose of 10 mg of Valium with 25 mg of amitriptyline and has felt much better since.
I can't find a Valium vaginal suppository anywhere, people! Any of you know about anything like this? I imagine that if you've got a stressed vagina, that would be as good of a cure as any, but I haven't heard of it yet. Any ideas?
It's weird because in his record, it's "hypernephrosis" and .....
Subject: It's weird because in his record, it's "hypernephrosis" and .....
I just had to put abdominal pain.
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